早期肠内营养加培菲康对重症急性胰腺炎患者血浆中炎症介质水平变化的效果

The Role of Short-Chain Fatty Acids in Acute Pancreatitis

Acute pancreatitis (AP) is a digestive emergency and can develop into a systematic illness. The role of the gut in the progression and deterioration of AP has drawn much attention from researchers, and areas of interest include dysbiosis of the intestinal flora, weakened intestinal barrier function, and bacterial and endotoxin translocation. Short-chain fatty acids (SCFAs), as one of the metabolites of gut microbiota, have been proven to be depleted in AP patients. SCFAs help restore gut homeostasis by rebuilding gut flora, stabilizing the intestinal epithelial barrier, and regulating inflammation. SCFAs can also suppress systematic inflammatory responses, improve the injured pancreas, and prevent and protect other organ dysfunctions. Based on multiple beneficial effects, increasing SCFAs is an essential idea of gut protective treatment in AP. Specific strategies include the direct use of butyrate or indirect supplementation through fiber, pre/pro/synbiotics, or fecal microbiota transplantation as a promising adjective therapy to enteral nutrition.

Benefits and harm of probiotics and synbiotics in adult critically ill patients. A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

BACKGROUND & AIMS

Several systematic reviews and meta-analyses of randomized controlled trials concluded that probiotics administration in critically ill patients was safe and associated with reduced rates of ventilator-associated pneumonia and diarrhea. However, a recent large multicenter trial found probiotics administration, compared to placebo, was not efficacious and increased adverse events. An updated meta-analysis that controls for type-1 and -2 errors using trial sequential analysis, with a detailed account of adverse events associated with probiotic administration, is warranted to confirm the safety and efficacy of probiotic use in critically ill patients.

METHODS

RCTs that compared probiotics or synbiotics to usual care or placebo and reported clinical and diarrheal outcomes were searched in 4 electronic databases from inception to March 8, 2022 without language restriction. Four reviewers independently extracted data and assessed the study qualities using the Critical Care Nutrition (CCN) Methodological Quality Scoring System. Random-effect meta-analysis and trial sequential analysis (TSA) were used to synthesize the results. The primary outcome was ventilator-associated pneumonia (VAP). The main subgroup analysis compared the effects of higher versus lower quality studies (based on median CCN score).

RESULTS

Seventy-five studies with 71 unique trials (n = 8551) were included. In the overall analysis, probiotics significantly reduced VAP incidence (risk ratio [RR] 0.70, 95% confidence interval [CI] 0.56-0.88; I² = 65%; 16 studies). However, such benefits were demonstrated only in lower (RR 0.47, 95% CI 0.32, 0.69; I² = 44%; 7 studies) but not higher quality studies (RR 0.89, 95% CI 0.73, 1.08; I² = 43%; 9 studies), with significant test for subgroup differences (p = 0.004). Additionally, TSA showed that the VAP benefits of probiotics in the overall and subgroup analyses were type-1 errors. In higher quality trials, TSA found that future trials are unlikely to demonstrate any benefits of probiotics on infectious complications and diarrhea. Probiotics had higher adverse events than control (pooled risk difference: 0.01, 95% CI 0.01, 0.02; I² = 0%; 22 studies).

CONCLUSION

High-quality RCTs did not support a beneficial effect of probiotics on clinical or diarrheal outcomes in critically ill patients. Given the lack of benefits and the increased incidence of adverse events, probiotics should not be routinely administered to critically ill patients.

PROSPERO REGISTRATION

CRD42022302278.

An Updated Systematic Review With Meta-analysis: Efficacy of Prebiotic, Probiotic, and Synbiotic Treatment of Patients With Severe Acute Pancreatitis

OBJECTIVES

The aim of this study was to systematically review the clinical outcomes of all randomized controlled trials of patients with severe acute pancreatitis (SAP) and treated with pre/pro/synbiotics.

METHODS

A systematic literature search of the MEDLINE, Embase, clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials was conducted. Eligible studies were randomized controlled trials that evaluated the clinical outcomes of patients with SAP treated with pre/pro/synbiotics.

RESULTS

Eleven trials comprising 930 patients were included. Patients treated with pre/pro/synbiotics had a significantly shorter hospital stay [weighted mean difference, -4.33 days; 95% confidence interval (CI), -7.71 to -0.95; P = 0.010; I2 = 66.9%] compared with control. In a subgroup analysis where only patients classified as SAP were included, those treated with pre/pro/synbiotics had lower risk of single- or multiple-organ failure (relative risk, 0.62; 95% CI, 0.44-0.88; P = 0.995; I2 = 0.0%) and decreased hospital stay (weighted mean difference, -0.65 days; 95% CI, -0.90 to -0.41; P = 0.121; I2 = 45.3%) compared with control.

CONCLUSIONS

Patients with SAP treated with pre/pro/synbiotics did not have a worse clinical outcome and had lower risk of organ failure and duration of hospital stay. Further studies should examine the optimal timing, type, and dosages of these promising treatments.

Supplemented Use of Pre-, Pro-, and Synbiotics in Severe Acute Pancreatitis: An Updated Systematic Review and Meta-Analysis of 13 Randomized Controlled Trials

Introduction: The role of pre-, pro-, and synbiotics supplemented to standard enteral nutrition in severe acute pancreatitis (SAP) remains unclear. We performed this updated meta-analysis to determine the value of pre-, pro- and synbiotics supplemented to standard enteral nutrition in predicted SAP.

Methods: A systematic search in PubMed, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases was performed. Eligible studies were randomized controlled trials (RCTs) that compared the effects of pre-, pro-, and synbiotics supplemented to standard enteral nutrition with control regime in predicted SAP patients. Risk ratio (RR) and mean difference (MD) with 95% confidence interval (95% CI) were used to express the estimates of dichotomous and continuous data respectively.

Results: 13 RCTs comprising an aggregate total of 950 patients were eventually enrolled. Pooled results suggested that supplemented use of pre-, pro- and synbiotics effectively shorten the length of hospital stay in Chinese SAP cohorts (6 RCTs, MD = −5.57, 95% CI = −8.21 to −2.93, P < 0.001); however significant differences with regard to remaining clinical outcomes were not detected for all patients. Further analysis based on category of interventions including pre-, pro- and synbiotics also confirmed the findings to be reliable.

Conclusions: Supplemented use of pre-, pro and synbiotics reduced the length of hospital stay in Chinese SAP cohorts. And thus, we concluded that pre-, pro- and synbiotics supplemented to standard enteral nutrition may be a potential option for the treatment of SAP patients. However, we also suggest designing further studies with large-scale and rigorous methods of addressing data to establish the effects and safety of supplemented use of pre-, pro- and synbiotics for SAP patients due to the presence of limitations.

Endoscopic intervention combined with somatostatin for treatment of patients with severe acute pancreatitis: Impact on clinical symptoms and relative biochemical indexes

AIM

To evaluate the effect of endoscopic intervention combined with somatostatin on clinical symptoms and biochemical indexes in patients with severe acute pancreatitis (SAP).

METHODS

One hundred and forty-eight patients with SAP treated from January 2015 to June 2016 at the Jiaxing First Hospital were divided into either an observation group or a control group. Both groups were given conventional therapy. The control group was given somatostatin infusion therapy, and the observation group was given endoscopic intervention combined with somatostatin artery perfusion therapy. Clinical symptoms, serum inflammatory factors, gastrointestinal hormones, and complications were compared between the two groups.

RESULTS

Times to remission of abdominal pain, high fever, and signs of peritoneal irritation were significantly shorter in the observation group than in the control group (t = 10.720, 8.226, 11.840, and 9.143, respectively; P < 0.05 or 0.01). Serum levels of interleukin-8, hypersensitive C-reactive protein, and tumor necrosis factor α were significantly lower in the observation group than in the control group (t = 17.509, 20.189, and 14.847, respectively; P < 0.01). Serum levels of vasoactive intestinal peptide and gastrin were significantly lower and that of motilin was significantly higher in the observation group than in the control group (t = 14.586, 11.374, and 7.126, respectively; P < 0.05 or 0.01). The incidence of pancreatic or surrounding tissue necrosis, pancreatic fistula, pancreatic abscess, and pancreatic pseudocyst was significantly lower in the observation group than in the control group (χ² = 7.306, 7.955, 8.976, and 5.049, respectively; P < 0.05 or 0.01).

CONCLUSION

Endoscopic intervention combined with somatostatin can help relieve the inflammatory response, modulate gastrointestinal function, improve the clinical symptoms, and reduce complications in patients with SAP.

Efficacy of early application of enteral nutrition combined with probiotics in treatment of severe acute pancreatitis

AIM: To assess the efficacy of early enteral nutrition and probiotics in the treatment of severe acute pancreatitis.

METHODS: A retrospective analysis was performed of the clinical data for patients with severe acute pancreatitis treated at our hospital during from January 2011 to December 2014. All patients were given basic treatments such as fasting, gastrointestinal decompression, inhibition of pancreatic secretion, and improving the balance of water and electrolyte. According to the method of nutrition supply, the patients were divided into two groups: an enteral nutrition (EN) group and an enteral nutrition+probiotics (EN + P) group. Inflammatory indicators, nutritional indicators, and the incidence of complications were compared between the two groups.

RESULTS: The patients' general situation and blood tests of the two groups were not significantly different. albumin was significantly higher, and C-reactive protein, C-reactive protein, totalparenteralnutrtion, pancreatic amylase, white blood cell, and endotoxin were significantly lower after treatment than before treatment in both groups (P < 0.05). These changes were significantly better in the EN + P group than in the EN group (P < 0.05). The incidence rates of infection and multiple organ dysfunction were significantly lower in the EN+P group than in the EN group (P < 0.05). The average length of hospital stay and cost were also significantly lower in the EN+P group than in the EN group (P < 0.05).

CONCLUSION: Early enteral nutrition combined with probiotics can not only improve the nutritional status, promote the recovery of gastrointestinal function and reduce the incidence of complications such as infection and multiple organ dysfunction in patients with severe acute pancreatitis, but also shorten the length of hospital stay and reduce the cost.