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Sirtl S, Hohmann E, Ahmad M, Bretthauer K, Junge M, Vornhülz M, Goni E, Saka D, Knoblauch M, Aghamaliyev U, Schulz C, Zorniak M, Mahajan UM, Mayerle J, Beyer G. Severity and outcome of a first episode of idiopathic acute pancreatitis is not more severe than pancreatitis of other etiologies. Pancreatology 2024:S1424-3903(24)00701-4. [PMID: 39147660 DOI: 10.1016/j.pan.2024.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 07/15/2024] [Accepted: 08/09/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND With respect to severity and outcome of an index episode of idiopathic acute pancreatitis the current literature reports conflicting retrospective results. One reason might be the retrospective study design precluding in depth analysis resulting in mixed etiologies and combination of index episode versus recurrent idiopathic acute pancreatitis. METHODS In this retrospective monocentric cohort study, we retrieved all patients with a first acute pancreatitis episode treated between 2005 and 2021 at the LMU University Hospital from our clinical information system based on the respective ICD-10 codes. In an initial sample of 1390 presumed idiopathic pancreatitis patients we identified 68 confirmed idiopathic acute pancreatitis patients and compared those to 75 first-time alcohol-induced acute pancreatitis patients and 390 first-time biliary-induced acute pancreatitis patients. Clinical outcome (severity, SIRS, mortality, and re-admission rate) was set as outcome measures. Multinomial logistic regression analysis was performed. RESULTS In alcohol-induced acute pancreatitis moderate and severe courses occur significantly more often when compared to idiopathic acute pancreatitis (17.33 % vs. 10.29 %; multinomial logistic regression p = 0.0021). There were no significant differences in mortality between first-time alcoholic, idiopathic and biliary pancreatitis (p = 0.6328). Patients with idiopathic acute pancreatitis had significantly more hospital readmissions (within 30 days) compared to alcohol-induced pancreatitis patients (p = 0.0284). CONCLUSION In the context of a first episode of acute pancreatitis, idiopathic acute pancreatitis remains a challenging diagnosis posing an increased risk of recurrence, but not an increased risk for a more severe disease course.
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Affiliation(s)
- Simon Sirtl
- Department of Medicine II, LMU University Hospital, Munich, Germany
| | - Eric Hohmann
- Department of Medicine II, LMU University Hospital, Munich, Germany
| | - Mahmood Ahmad
- Department of Medicine II, LMU University Hospital, Munich, Germany
| | | | - Mali Junge
- Department of Medicine II, LMU University Hospital, Munich, Germany
| | - Marlies Vornhülz
- Department of Medicine II, LMU University Hospital, Munich, Germany
| | - Elisabetta Goni
- Department of Medicine II, LMU University Hospital, Munich, Germany
| | - Didem Saka
- Department of Medicine II, LMU University Hospital, Munich, Germany
| | - Mathilda Knoblauch
- Department of General, Visceral, and Transplantation Surgery, LMU University Hospital, Munich, Germany
| | - Ughur Aghamaliyev
- Department of General, Visceral, and Transplantation Surgery, LMU University Hospital, Munich, Germany
| | - Christian Schulz
- Department of Medicine II, LMU University Hospital, Munich, Germany
| | - Michal Zorniak
- Department of Medicine II, LMU University Hospital, Munich, Germany; Endoscopy Department, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Ujjwal M Mahajan
- Department of Medicine II, LMU University Hospital, Munich, Germany
| | - Julia Mayerle
- Department of Medicine II, LMU University Hospital, Munich, Germany.
| | - Georg Beyer
- Department of Medicine II, LMU University Hospital, Munich, Germany
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2
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Shi C, Liu S, Zheng M, Yan F, Xu D, Wang W, Chen J. Phospholipid and glycerolipid metabolism as potential diagnostic biomarkers for acute pancreatitis. Lipids Health Dis 2024; 23:223. [PMID: 39044297 PMCID: PMC11265382 DOI: 10.1186/s12944-024-02217-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 07/15/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Acute pancreatitis (AP) is characterized as a systemic inflammatory condition posing challenges in diagnosis and prognosis assessment. Lipid metabolism abnormalities, especially triacylglycerol (TAG) levels, have been reported, indicating their potential as biomarkers in acute pancreatitis. However, the performance of the TAG cycle, including phospholipid and glycerolipid metabolism, in AP patients has not yet been reported. METHODS This study enrolled 91 patients with acute biliary pancreatitis (ABP), 27 with hyperlipidaemic acute pancreatitis (HLAP), and 58 healthy controls (HCs), and their plasma phospholipid and glycerolipid levels were analyzed through liquid chromatography‒mass spectrometry. The phospholipid and glycerolipid contents of plasma collected from AP patients on the first, third, and seventh days of hospitalization were also measured. An orthogonal partial least squares discriminant analysis model served to differentiate the ABP, HLAP and HC groups, and potentially diagnostic lipids were evaluated via receiver operating characteristic curves in both the test and validation sets. Correlations between clinical data and lipids were conducted using Spearman's method. Clustering via the 'mfuzz' R package and the Kruskal‒Wallis H test were conducted to monitor changes during hospitalization. RESULTS Compared with those in HCs, the levels of phosphatidylcholine (PC), phosphatidylethanolamine (PE), and phosphatidic acid (PA) were lower in AP patients, whereas the levels of phosphatidylinositol (PI) and phosphatidylglycerol (PG) showed the opposite trend. Interestingly, TAG levels were positively correlated with white blood cell counts in ABP patients, and TAGs containing 44-55 carbon atoms were highly correlated with plasma TAG levels in HLAP patients. Phospholipid levels exhibited an inverse correlation with AP markers, in contrast to glycerolipids, which demonstrated a positive correlation with these markers. Additionally, PE (O-16:0/20:4) and PE (18:0/22:6) emerged as potential biomarkers because of their ability to distinguish ABP and HLAP patients from HCs, showing area under the curve (AUC) values of 0.932 and 0.962, respectively. PG (16:0/18:2), PG (16:0/20:4), PE (P-16:0/20:2), PE (P-18:2/18:2), PE (P-18:1/20:3), PE (P-18:1/20:4), PE (O-16:0/20:4), and TAG (56:6/FA18:0) were significantly changed in ABP patients who improved. For HLAP patients, PC (18:0/20:3), TAG (48:3/FA18:1), PE (P-18:0/16:0), and TAG (48:4/FA18:2) showed different trends in patients with improvement and deterioration, which might be used for prognosis. CONCLUSIONS Phospholipids and glycerolipids were found to be potential biomarkers in acute pancreatitis, which offers new diagnostic and therapeutic insights into this disease.
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Affiliation(s)
- Chunfeng Shi
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, 362000, Fujian, China
| | - Shengwei Liu
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Xiamen Medical College, Xiamen, 36100, Fujian, China
| | - Meihua Zheng
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, 362000, Fujian, China
| | - Furong Yan
- Clinical Center for Molecular Diagnosis and Therapy, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, 362000, Fujian, China
| | - Dongyao Xu
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, 362000, Fujian, China
| | - Wei Wang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, 362000, Fujian, China.
| | - Jin Chen
- Clinical Center for Molecular Diagnosis and Therapy, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, 362000, Fujian, China.
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3
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Hallensleben ND, Stassen PMC, Schepers NJ, Besselink MG, Anten MPGF, Bakker OJ, Bollen TL, da Costa DW, van Dijk SM, van Dullemen HM, Dijkgraaf MGW, van Eijck B, van Eijck CHJ, Erkelens W, Erler NS, Fockens P, van Geenen EJM, van Grinsven J, Hazen WL, Hollemans RA, van Hooft JE, Jansen JM, Kubben FJGM, Kuiken SD, Poen AC, Quispel R, de Ridder RJ, Römkens TEH, Schoon EJ, Schwartz MP, Seerden TCJ, Smeets XJNM, Spanier BWM, Tan ACITL, Thijs WJ, Timmer R, Umans DS, Venneman NG, Verdonk RC, Vleggaar FP, van de Vrie W, van Wanrooij RLJ, Witteman BJ, van Santvoort HC, Bouwense SAW, Bruno MJ. Patient selection for urgent endoscopic retrograde cholangio-pancreatography by endoscopic ultrasound in predicted severe acute biliary pancreatitis (APEC-2): a multicentre prospective study. Gut 2023; 72:1534-1542. [PMID: 36849226 DOI: 10.1136/gutjnl-2022-328258] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 02/13/2023] [Indexed: 03/01/2023]
Abstract
OBJECTIVE Routine urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic biliary sphincterotomy (ES) does not improve outcome in patients with predicted severe acute biliary pancreatitis. Improved patient selection for ERCP by means of endoscopic ultrasonography (EUS) for stone/sludge detection may challenge these findings. DESIGN A multicentre, prospective cohort study included patients with predicted severe acute biliary pancreatitis without cholangitis. Patients underwent urgent EUS, followed by ERCP with ES in case of common bile duct stones/sludge, within 24 hours after hospital presentation and within 72 hours after symptom onset. The primary endpoint was a composite of major complications or mortality within 6 months after inclusion. The historical control group was the conservative treatment arm (n=113) of the randomised APEC trial (Acute biliary Pancreatitis: urgent ERCP with sphincterotomy versus conservative treatment, patient inclusion 2013-2017) applying the same study design. RESULTS Overall, 83 patients underwent urgent EUS at a median of 21 hours (IQR 17-23) after hospital presentation and at a median of 29 hours (IQR 23-41) after start of symptoms. Gallstones/sludge in the bile ducts were detected by EUS in 48/83 patients (58%), all of whom underwent immediate ERCP with ES. The primary endpoint occurred in 34/83 patients (41%) in the urgent EUS-guided ERCP group. This was not different from the 44% rate (50/113 patients) in the historical conservative treatment group (risk ratio (RR) 0.93, 95% CI 0.67 to 1.29; p=0.65). Sensitivity analysis to correct for baseline differences using a logistic regression model also showed no significant beneficial effect of the intervention on the primary outcome (adjusted OR 1.03, 95% CI 0.56 to 1.90, p=0.92). CONCLUSION In patients with predicted severe acute biliary pancreatitis without cholangitis, urgent EUS-guided ERCP with ES did not reduce the composite endpoint of major complications or mortality, as compared with conservative treatment in a historical control group. TRIAL REGISTRATION NUMBER ISRCTN15545919.
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Affiliation(s)
- Nora D Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Pauline M C Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, Noord-Holland, The Netherlands
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Sint Franciscus Vlietland Groep, Rotterdam, Zuid-Holland, The Netherlands
| | - Olaf J Bakker
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Thomas L Bollen
- Department of Radiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - David W da Costa
- Department of Radiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Sven M van Dijk
- Department of Surgery, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology, Universtiy of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
- Methodology department, Amsterdam Public Health Research Institute, Amsterdam, North Holland, The Netherlands
| | - Brechje van Eijck
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, Noord-Holland, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospitals, Apeldoorn, Gelderland, The Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | | | | | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, Noord-Brabant, The Netherlands
| | - Robbert A Hollemans
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology, OLVG, Amsterdam, Noord-Holland, The Netherlands
| | - Frank J G M Kubben
- Department of Gastroenterology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, Noord-Holland, The Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Hospital, Zwolle, Overijssel, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, Zuid-Holland, The Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Ziekenhuis, Den Bosch, Noord-Brabant, The Netherlands
| | - Erik J Schoon
- Gastroenterology, Catharina Hospital, Eindhoven, The Netherlands
| | - Matthijs P Schwartz
- Department of Internal Medicine and Gastroenterology, Meander Medical Center, Amersfoort, The Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Xavier J N M Smeets
- Gastroenterology and Hepatology, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, Groningen, The Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Devica S Umans
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Heptatology, Albert Schweitzer Hospital, Dordrecht, Zuid-Holland, The Netherlands
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Ben J Witteman
- Department of Gastroenterology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Dutch Acute Pancreatitis Study Group, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht Universitair Medisch Centrum+, Maastricht, Limburg, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
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4
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Hallensleben ND, Timmerhuis HC, Hollemans RA, Pocornie S, van Grinsven J, van Brunschot S, Bakker OJ, van der Sluijs R, Schwartz MP, van Duijvendijk P, Römkens T, Stommel MWJ, Verdonk RC, Besselink MG, Bouwense SAW, Bollen TL, van Santvoort HC, Bruno MJ. Optimal timing of cholecystectomy after necrotising biliary pancreatitis. Gut 2022; 71:974-982. [PMID: 34272261 DOI: 10.1136/gutjnl-2021-324239] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 07/07/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Following an episode of acute biliary pancreatitis, cholecystectomy is advised to prevent recurrent biliary events. There is limited evidence regarding the optimal timing and safety of cholecystectomy in patients with necrotising biliary pancreatitis. DESIGN A post hoc analysis of a multicentre prospective cohort. Patients with biliary pancreatitis and a CT severity score of three or more were included in 27 Dutch hospitals between 2005 and 2014. Primary outcome was the optimal timing of cholecystectomy in patients with necrotising biliary pancreatitis, defined as: the optimal point in time with the lowest risk of recurrent biliary events and the lowest risk of complications of cholecystectomy. Secondary outcomes were the number of recurrent biliary events, periprocedural complications of cholecystectomy and the protective value of endoscopic sphincterotomy for the recurrence of biliary events. RESULTS Overall, 248 patients were included in the analysis. Cholecystectomy was performed in 191 patients (77%) at a median of 103 days (P25-P75: 46-222) after discharge. Infected necrosis after cholecystectomy occurred in four (2%) patients with persistent peripancreatic collections. Before cholecystectomy, 66 patients (27%) developed biliary events. The risk of overall recurrent biliary events prior to cholecystectomy was significantly lower before 10 weeks after discharge (risk ratio 0.49 (95% CI 0.27 to 0.90); p=0.02). The risk of recurrent pancreatitis before cholecystectomy was significantly lower before 8 weeks after discharge (risk ratio 0.14 (95% CI 0.02 to 1.0); p=0.02). The complication rate of cholecystectomy did not decrease over time. Endoscopic sphincterotomy did not reduce the risk of recurrent biliary events (OR 1.40 (95% CI 0.74 to 2.83)). CONCLUSION The optimal timing of cholecystectomy after necrotising biliary pancreatitis, in the absence of peripancreatic collections, is within 8 weeks after discharge.
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Affiliation(s)
- Nora D Hallensleben
- Department of Gastroenterology, Erasmus Medical Center, Rotterdam, The Netherlands .,Department of Research and Development, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Hester C Timmerhuis
- Department of Research and Development, Sint Antonius Hospital, Nieuwegein, The Netherlands.,Department of Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Robbert A Hollemans
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Surgery, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Sabrina Pocornie
- Department of Research and Development, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Janneke van Grinsven
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Sandra van Brunschot
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olaf J Bakker
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Rogier van der Sluijs
- Department of Radiology, Center for Artificial Intelligence in Medicine and Imaging Stanford University, Stanford, California, USA
| | - Matthijs P Schwartz
- Department of Internal Medicine and Gastroenterology, Meander Medical Center, Amersfoort, The Netherlands
| | | | - Tessa Römkens
- Gastroenterology and Hepatology, Jeroen Bosch Ziekenhuis, Den Bosch, The Netherlands
| | | | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Marc G Besselink
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | | | - Thomas L Bollen
- Department of Radiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands.,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marco J Bruno
- Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, The Netherlands
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Gliem N, Ammer-Herrmenau C, Ellenrieder V, Neesse A. Management of Severe Acute Pancreatitis: An Update. Digestion 2021; 102:503-507. [PMID: 32422634 PMCID: PMC8315686 DOI: 10.1159/000506830] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/19/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Severe acute pancreatitis (AP) continues to be a serious gastrointestinal disease with relevant morbidity and mortality. SUMMARY Successful clinical management requires close interdisciplinary cooperation and coordination from experienced gastroenterologists, intensive care physicians, surgeons, and radiologists. While the early phase of the disease is characterized by intensive care aspects that focus primarily on treatment of organ failure, later complications are characterized especially by (infected) necrotic collections. Here, we discuss current clinical standards and developments for conservative and interventional management of patients with severe AP. Key messages: Early targeted fluid therapy within the first 48 h is critical to improve the outcome of severe AP. Thoracic epidural analgesia may have prognostically beneficial effects due to suspected anti-inflammatory effects and increased perfusion of splanchnic vessels. Enteral feeding should be started early during severe AP. Persistent organ failure (>48 h) is the strongest predictor of poor prognosis, and local complications such as infected walled-off necrosis should be primarily treated by minimally invasive endoscopic step-up approaches that are usually superior to surgical therapy options.
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Affiliation(s)
| | | | | | - Albrecht Neesse
- *Dr. Albrecht Neesse, Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre Goettingen, Robert-Koch-Strasse 40, DE–37075 Goettingen (Germany),
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6
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Novikov AA, Fieber JH, Saumoy M, Rosenblatt R, Mekelburg SAC, Shah SL, Crawford CV. ERCP improves mortality in acute biliary pancreatitis without cholangitis. Endosc Int Open 2021; 9:E927-E933. [PMID: 34079880 PMCID: PMC8159624 DOI: 10.1055/a-1320-0041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022] Open
Abstract
Background and study aims Acute pancreatitis (AP) is an increasingly common indication for hospitalization in the United States. The necessity for endoscopic retrograde cholangiopancreatography (ERCP) and the timing of ERCP in acute gallstone-related pancreatitis without cholangitis (AGPNC) is controversial. The aim of this study was to evaluate the association of ERCP and its performance during admission with mortality and length of stay (LOS) in patients with AGPNC. Patients and methods We queried the Nationwide Inpatient Sample (NIS) from 2004 to 2014 to identify all patients with admissions for gallstone AP. We excluded patients with chronic pancreatitis or concurrent cholangitis, and those who were transferred from elsewhere for treatment. Our primary outcome measure was inpatient mortality. Our secondary outcome measure was hospital length of stay (LOS). Results We identified 491,011 records eligible for analysis. Of the patients, 30.6 % (150,101) had AGPNC. There were 1.34 deaths per 100 admissions in patients with AGPNC. The average LOS was 5.88 (± 6.38) days with a median stay of 4 days (range, 3-7). When adjusted for age, Elixhauser Comorbidity Index, and severe pancreatitis, patients with ERCP during admission were 43 % less likely to die. ERCP performed between Days 3 and 9 of hospitalization resulted in a significant mortality benefit. Among those who had ERCP, a shorter wait time for ERCP was associated with a shorter LOS after adjustment for demographics and severity of illness. Conclusion ERCP performed during inpatient admission for AGPNC was associated with decreased mortality. These data support early ERCP in patients with acute gallstone pancreatitis without cholangitis.
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Affiliation(s)
- Aleksey A. Novikov
- Department of Gastroenterology, Doylestown Hospital, Doylestown, Pennsylvania, United States
| | - Jennifer H. Fieber
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Department of Surgery, Hospital of the University of Pennsylvania,
Philadelphia, Pennsylvania, United States
| | - Monica Saumoy
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, United States
| | | | - Shawn L. Shah
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, United States
| | - Carl V. Crawford
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, United States
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7
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Buonocore MR, Germani U, Castellani D, Petrogiannopoulos L, Pallio S, Piciucchi M, Sbrozzi-Vanni A, Zullo A, Manta R. Timing of endoscopic therapy for acute bilio-pancreatic diseases: a practical overview. Ann Gastroenterol 2021; 34:125-129. [PMID: 33654349 PMCID: PMC7903577 DOI: 10.20524/aog.2021.0580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 08/13/2020] [Indexed: 12/24/2022] Open
Abstract
Diseases of the pancreas and hepatobiliary tree often require a therapeutic approach with endoscopic retrograde cholangiopancreatography (ERCP), generally following noninvasive imaging techniques. Appropriate indications and the correct timing for urgent ERCP would benefit both patients and clinicians and allow optimal utilization of health resources. Indications for urgent (<24 h) ERCP include severe acute cholangitis, acute biliary pancreatitis with cholangitis, biliary or pancreatic leaks, in the absence of percutaneous drainage, and severe acute cholecystitis in patients who are unfit for surgery and do not respond to conservative management. In patients who have severe acute biliary pancreatitis with ongoing biliary obstruction but without cholangitis, early (<48-72 h) ERCP is indicated. This overview aims to provide decisional flowcharts that can be easily used for managing patients with acute bilio-pancreatic disorders when they are referred to the Emergency Department.
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Affiliation(s)
- Matteo Rossano Buonocore
- Gastroenterology and Digestive Endoscopy Unit, General Hospital of Perugia (Matteo Rossano Buonocore, Ugo Germani, Danilo Castellani, Leonidas Petrogiannopoulos, Raffaele Manta)
| | - Ugo Germani
- Gastroenterology and Digestive Endoscopy Unit, General Hospital of Perugia (Matteo Rossano Buonocore, Ugo Germani, Danilo Castellani, Leonidas Petrogiannopoulos, Raffaele Manta)
| | - Danilo Castellani
- Gastroenterology and Digestive Endoscopy Unit, General Hospital of Perugia (Matteo Rossano Buonocore, Ugo Germani, Danilo Castellani, Leonidas Petrogiannopoulos, Raffaele Manta)
| | - Leonidas Petrogiannopoulos
- Gastroenterology and Digestive Endoscopy Unit, General Hospital of Perugia (Matteo Rossano Buonocore, Ugo Germani, Danilo Castellani, Leonidas Petrogiannopoulos, Raffaele Manta)
| | - Socrate Pallio
- Digestive Endoscopy Unit "G. Martino", General Hospital Messina (Socrate Pallio)
| | - Matteo Piciucchi
- Gastroenterology and Digestive Endoscopy Unit, General Hospital of Orvieto (Matteo Piciucchi)
| | - Andrea Sbrozzi-Vanni
- Digestive Endoscopy Unit, Apuane General Hospital of Massa (Andrea Sbrozzi-Vanni)
| | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy, "Nuovo Regina Margherita" Hospital, Rome (Angelo Zullo), Italy
| | - Raffaele Manta
- Gastroenterology and Digestive Endoscopy Unit, General Hospital of Perugia (Matteo Rossano Buonocore, Ugo Germani, Danilo Castellani, Leonidas Petrogiannopoulos, Raffaele Manta)
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8
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Zheng Z, Ding YX, Qu YX, Cao F, Li F. A narrative review of acute pancreatitis and its diagnosis, pathogenetic mechanism, and management. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:69. [PMID: 33553362 PMCID: PMC7859757 DOI: 10.21037/atm-20-4802] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute pancreatitis (AP) is an inflammatory disease that can progress to severe acute pancreatitis (SAP), which increases the risk of death. AP is characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. Other contributing factors may include calcium (Ca2+) overload, mitochondrial dysfunction, impaired autophagy, and endoplasmic reticulum (ER) stress. In addition, exosomes are also associated with pathophysiological processes of many human diseases and may play a biological role in AP. However, the pathogenic mechanism has not been fully elucidated and needs to be further explored to inform treatment. Recently, the treatment guidelines have changed; minimally invasive therapy is advocated more as the core multidisciplinary participation and "step-up" approach. The surgical procedures have gradually changed from open surgery to minimally invasive surgery that primarily includes percutaneous catheter drainage (PCD), endoscopy, small incision surgery, and video-assisted surgery. The current guidelines for the management of AP have been updated and revised in many aspects. The type of fluid to be used, the timing, volume, and speed of administration for fluid resuscitation has been controversial. In addition, the timing and role of nutritional support and prophylactic antibiotic therapy, as well as the timing of the surgical or endoscopic intervention, and the management of complications still have many uncertainties that could negatively impact the prognosis and patients' quality of life. Consequently, to inform clinicians about optimal treatment, we aimed to review recent advances in the understanding of the pathogenesis of AP and its diagnosis and management.
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Affiliation(s)
- Zhi Zheng
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Yi-Xuan Ding
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Yuan-Xu Qu
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Feng Cao
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Fei Li
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
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Abstract
Geriatric patients tend to have subtle presentations of biliary disorders and, if untreated, can decompensate acutely. Each biliary disorder warrants formulation of an individualized treatment plan with a multidisciplinary approach. Acute cholecystitis, a common complication of gallstones, is initially managed by conservative measures and subsequently, among patients with optimal surgical risk, through laparoscopic or open cholecystectomy. High-risk patients undergo temporization, percutaneous or endoscopic, followed by definitive intervention. Acute cholecystitis with complications (ie, perforation, gangrene, or small bowel obstruction) warrants emergent cholecystectomy. Gallstone migration into the biliary system can cause choledocholithiasis, often complicated by biliary pancreatitis or cholangitis if not intervened. Therapy for choledocholithiasis is based on biliary clearance through endoscopic and, infrequently, surgical approaches.
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Abstract
Acute pancreatitis is one of the most common gastrointestinal causes for hospitalization. In 15-20% it evolves into severe necrotizing pancreatitis. Recent studies have shown no association between the initiation of antibiotic therapy in acute pancreatitis and severe outcomes such as organ failure, infection of pancreatic necrosis, extrapancreatic infections or mortality. Specific subgroups with predicted severe acute pancreatitis or both extensive sterile necrosis and persistent organ failure may benefit from prophylactic antibiotics. Local infection develops in 30% of patients with pancreatic necrosis and results in morbidity and mortality. Contrast enhanced computed tomography should be performed in all patients with acute pancreatitis who develop sepsis, organ failure or fail to improve. C-reactive protein is an independent predictor of severe acute pancreatitis. Procalcitonin is the most sensitive laboratory test for detection of pancreatic infection. Antibiotics do however play a large role in patients with suspected or confirmed infected pancreatic necrosis and extrapancreatic infections. In clinical practice most clinicians prescribe antibiotics in the first 3 days of acute pancreatitis which in turns lead to excessive, unjustified use of antibiotics. Deep knowledge of the recent guidelines combined with an individualized management based on right clinical judgment is a rationale approach of patients with acute pancreatitis.
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Affiliation(s)
- Vasiliki Soulountsi
- 1st Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece
| | - Theodoros Schizodimos
- 2nd Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece
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11
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Yu B, Li N, Li J, Wan J, He W, Zhu Y, Lu N. The Clinical Characteristics of Acute Pancreatitis in Gerontal Patients: A Retrospective Study. Clin Interv Aging 2020; 15:1541-1553. [PMID: 32982192 PMCID: PMC7493010 DOI: 10.2147/cia.s259920] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/28/2020] [Indexed: 12/12/2022] Open
Abstract
Background The incidence of acute pancreatitis (AP) in ageing patients has increased in recent years, and results regarding the clinical outcomes of these patients are controversial. The aim of this study was to compare the clinical outcomes of AP in ageing patients over 60 years old. Methods Eighty patients aged ≥80 years (oldest group) were compared to 393 patients aged 60 to 79 years (older group). The clinical course and biochemical and radiological data were evaluated. The primary endpoints were mortality rate, intensive care unit (ICU) admission rate and in-hospital length of stay (LOS). The secondary endpoints were the incidence of operative treatment and complications of AP. Results Abdominal pain (61.3% vs 46.3%, P=0.013) was less common in the oldest group. Jaundice (17.5% vs 8.9%, P=0.021) and dyspnoea (26.3% vs 11.5%, P=0.001) were more obvious in the oldest group than in the older group. The mean BMI was lower in the oldest group than in the older group (21.07±3.18 vs 22.36±2.89, P = 0.001). Age over 80 years (P=0.011) and organ failure (P<0.05) were independent risk factors for mortality. More severe AP (P=0.001), abdominal pain (P=0.033) and organ failure (P<0.05) were associated with the ICU admission rate. Age over 80 years (P=0.001), more severe AP (P=0.001), female sex (P=0.018), jaundice (P=0.038), operative treatment (P<0.05) and organ failure (P<0.05) were risk factors for increased LOS. Conclusion The oldest group had a higher death rate and longer LOS than the older group. More attention should be given to the clinical symptoms of this frail population. We propose that more comprehensive and goal-directed attendant diagnostic procedures should be performed to detect the disease early and to improve the outcomes of ageing patients.
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Affiliation(s)
- Bingjun Yu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, People's Republic of China
| | - Nianshuang Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, People's Republic of China
| | - Jiarong Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, People's Republic of China
| | - Jianhua Wan
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, People's Republic of China
| | - Wenhua He
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, People's Republic of China
| | - Yin Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, People's Republic of China
| | - Nonghua Lu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, People's Republic of China
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12
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Umans DS, Timmerhuis HC, Hallensleben ND, Bouwense SA, Anten MPG, Bhalla A, Bijlsma RA, Boermeester MA, Brink MA, Hol L, Bruno MJ, Curvers WL, van Dullemen HM, van Eijck BC, Erkelens GW, Fockens P, van Geenen EJM, Hazen WL, Hoge CV, Inderson A, Kager LM, Kuiken SD, Perk LE, Poley JW, Quispel R, Römkens TE, van Santvoort HC, Tan AC, Thijssen AY, Venneman NG, Vleggaar FP, Voorburg AM, van Wanrooij RL, Witteman BJ, Verdonk RC, Besselink MG, van Hooft JE. Role of endoscopic ultrasonography in the diagnostic work-up of idiopathic acute pancreatitis (PICUS): study protocol for a nationwide prospective cohort study. BMJ Open 2020; 10:e035504. [PMID: 32819938 PMCID: PMC7440829 DOI: 10.1136/bmjopen-2019-035504] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 06/10/2020] [Accepted: 07/15/2020] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Idiopathic acute pancreatitis (IAP) remains a dilemma for physicians as it is uncertain whether patients with IAP may actually have an occult aetiology. It is unclear to what extent additional diagnostic modalities such as endoscopic ultrasonography (EUS) are warranted after a first episode of IAP in order to uncover this aetiology. Failure to timely determine treatable aetiologies delays appropriate treatment and might subsequently cause recurrence of acute pancreatitis. Therefore, the aim of the Pancreatitis of Idiopathic origin: Clinical added value of endoscopic UltraSonography (PICUS) Study is to determine the value of routine EUS in determining the aetiology of pancreatitis in patients with a first episode of IAP. METHODS AND ANALYSIS PICUS is designed as a multicentre prospective cohort study of 106 patients with a first episode of IAP after complete standard diagnostic work-up, in whom a diagnostic EUS will be performed. Standard diagnostic work-up will include a complete personal and family history, laboratory tests including serum alanine aminotransferase, calcium and triglyceride levels and imaging by transabdominal ultrasound, magnetic resonance imaging or magnetic resonance cholangiopancreaticography after clinical recovery from the acute pancreatitis episode. The primary outcome measure is detection of aetiology by EUS. Secondary outcome measures include pancreatitis recurrence rate, severity of recurrent pancreatitis, readmission, additional interventions, complications, length of hospital stay, quality of life, mortality and costs, during a follow-up period of 12 months. ETHICS AND DISSEMINATION PICUS is conducted according to the Declaration of Helsinki and Guideline for Good Clinical Practice. Five medical ethics review committees assessed PICUS (Medical Ethics Review Committee of Academic Medical Center, University Medical Center Utrecht, Radboud University Medical Center, Erasmus Medical Center and Maastricht University Medical Center). The results will be submitted for publication in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER Netherlands Trial Registry (NL7066). Prospectively registered.
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Affiliation(s)
- Devica S Umans
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Research and Development, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Hester C Timmerhuis
- Research and Development, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
- Department of Surgery, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Nora D Hallensleben
- Research and Development, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Marie-Paule Gf Anten
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, HagaZiekenhuis, Den Haag, Zuid-Holland, The Netherlands
| | - Rina A Bijlsma
- Department of Gastroenterology and Hepatology, Martini Ziekenhuis, Groningen, Groningen, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
| | - Menno A Brink
- Department of Gastroenterology and Hepatology, Meander MC, Amersfoort, Utrecht, The Netherlands
| | - Lieke Hol
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, North Brabant, The Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, UMCG, Groningen, Groningen, The Netherlands
| | - Brechje C van Eijck
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, Noord-Holland, The Netherlands
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Ziekenhuizen, Apeldoorn, Gelderland, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud university medical center, Nijmegen, the Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, Noord-Brabant, The Netherlands
| | - Chantal V Hoge
- Department of Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, LUMC, Leiden, Zuid-Holland, The Netherlands
| | - Liesbeth M Kager
- Department of Gastroenterology and Hepatology, Noordwest Ziekenhuisgroep, Alkmaar, Noord-Holland, The Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, Noord-Holland, The Netherlands
| | - Lars E Perk
- Department of Gastroenterology and Hepatology, Medisch Centrum Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Groep, Delft, Zuid-Holland, The Netherlands
| | - Tessa Eh Römkens
- Department of Gastroenteroloy and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, Noord-Brabant, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Adriaan Citl Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, Gelderland, The Netherlands
| | - Annemieke Y Thijssen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Ziekenhuis, Dordrecht, Zuid-Holland, The Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Overijssel, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Annet McJ Voorburg
- Department of Gastroenterology and Hepatology, Diakonessenhuis Utrecht Zeist Doorn, Utrecht, Utrecht, The Netherlands
| | - Roy Lj van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
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13
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Schepers NJ, Hallensleben NDL, Besselink MG, Anten MPGF, Bollen TL, da Costa DW, van Delft F, van Dijk SM, van Dullemen HM, Dijkgraaf MGW, van Eijck CHJ, Erkelens GW, Erler NS, Fockens P, van Geenen EJM, van Grinsven J, Hollemans RA, van Hooft JE, van der Hulst RWM, Jansen JM, Kubben FJGM, Kuiken SD, Laheij RJF, Quispel R, de Ridder RJJ, Rijk MCM, Römkens TEH, Ruigrok CHM, Schoon EJ, Schwartz MP, Smeets XJNM, Spanier BWM, Tan ACITL, Thijs WJ, Timmer R, Venneman NG, Verdonk RC, Vleggaar FP, van de Vrie W, Witteman BJ, van Santvoort HC, Bakker OJ, Bruno MJ. Urgent endoscopic retrograde cholangiopancreatography with sphincterotomy versus conservative treatment in predicted severe acute gallstone pancreatitis (APEC): a multicentre randomised controlled trial. Lancet 2020; 396:167-176. [PMID: 32682482 DOI: 10.1016/s0140-6736(20)30539-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND It remains unclear whether urgent endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy improves the outcome of patients with gallstone pancreatitis without concomitant cholangitis. We did a randomised trial to compare urgent ERCP with sphincterotomy versus conservative treatment in patients with predicted severe acute gallstone pancreatitis. METHODS In this multicentre, parallel-group, assessor-masked, randomised controlled superiority trial, patients with predicted severe (Acute Physiology and Chronic Health Evaluation II score ≥8, Imrie score ≥3, or C-reactive protein concentration >150 mg/L) gallstone pancreatitis without cholangitis were assessed for eligibility in 26 hospitals in the Netherlands. Patients were randomly assigned (1:1) by a web-based randomisation module with randomly varying block sizes to urgent ERCP with sphincterotomy (within 24 h after hospital presentation) or conservative treatment. The primary endpoint was a composite of mortality or major complications (new-onset persistent organ failure, cholangitis, bacteraemia, pneumonia, pancreatic necrosis, or pancreatic insufficiency) within 6 months of randomisation. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, ISRCTN97372133. FINDINGS Between Feb 28, 2013, and March 1, 2017, 232 patients were randomly assigned to urgent ERCP with sphincterotomy (n=118) or conservative treatment (n=114). One patient from each group was excluded from the final analysis because of cholangitis (urgent ERCP group) and chronic pancreatitis (conservative treatment group) at admission. The primary endpoint occurred in 45 (38%) of 117 patients in the urgent ERCP group and in 50 (44%) of 113 patients in the conservative treatment group (risk ratio [RR] 0·87, 95% CI 0·64-1·18; p=0·37). No relevant differences in the individual components of the primary endpoint were recorded between groups, apart from the occurrence of cholangitis (two [2%] of 117 in the urgent ERCP group vs 11 [10%] of 113 in the conservative treatment group; RR 0·18, 95% CI 0·04-0·78; p=0·010). Adverse events were reported in 87 (74%) of 118 patients in the urgent ERCP group versus 91 (80%) of 114 patients in the conservative treatment group. INTERPRETATION In patients with predicted severe gallstone pancreatitis but without cholangitis, urgent ERCP with sphincterotomy did not reduce the composite endpoint of major complications or mortality, compared with conservative treatment. Our findings support a conservative strategy in patients with predicted severe acute gallstone pancreatitis with an ERCP indicated only in patients with cholangitis or persistent cholestasis. FUNDING The Netherlands Organization for Health Research and Development, Fonds NutsOhra, and the Dutch Patient Organization for Pancreatic Diseases.
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Affiliation(s)
- Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands.
| | - Nora D L Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Franciscus and Vlietland Hospital, Rotterdam, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - David W da Costa
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Sven M van Dijk
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, Netherlands
| | - Marcel G W Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospital, Apeldoorn, Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Janneke van Grinsven
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | | | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Netherlands
| | | | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Frank J G M Kubben
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Robert J F Laheij
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, Netherlands
| | - Rogier J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Marno C M Rijk
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, Netherlands
| | - Carola H M Ruigrok
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, Netherlands
| | - Xavier J N M Smeets
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, Netherlands
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Willem J Thijs
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Wim van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Olaf J Bakker
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
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14
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Hallensleben ND, Umans DS, Bouwense SAW, Verdonk RC, Romkens TEH, Witteman BJ, Schwartz MP, Spanier MB, Laheij R, van Santvoort HC, Besselink MG, van Hooft JE, Bruno MJ. The diagnostic work-up and outcomes of 'presumed' idiopathic acute pancreatitis: A post-hoc analysis of a multicentre observational cohort. United European Gastroenterol J 2020; 8:340-350. [PMID: 32213015 PMCID: PMC7184667 DOI: 10.1177/2050640619890462] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/28/2019] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION After standard diagnostic work-up, the aetiology of acute pancreatitis remains unknown in 16-27% of cases, a condition referred to as idiopathic acute pancreatitis (IAP). Determining the aetiology of pancreatitis is essential, as it may direct treatment in the acute phase and guides interventions to prevent recurrent pancreatitis. METHODS Between 2008 and 2015, patients with acute pancreatitis were registered prospectively in 19 Dutch hospitals. Patients who had a negative initial diagnostic work-up with regard to the underlying aetiology of their pancreatitis were labelled 'presumed' IAP. The aim of this study was to assess the use of diagnostic modalities and their yield to establish an aetiology in 'presumed' IAP, and to assess recurrence rates both with and without treatment. RESULTS Out of the 1632 registered patients, 191 patients had a first episode of 'presumed' IAP, of whom 176 (92%) underwent additional diagnostic testing: CT (n = 124, diagnostic yield 8%), EUS (n = 62, yield 35%), MRI/MRCP (n = 56, yield 33%), repeat ultrasound (n = 97, yield 21%), IgG4 (n = 54, yield 9%) and ERCP (n = 15, yield 47%). In 64 of 176 patients (36%) an aetiological diagnosis was established, mostly biliary (n = 39). In 13 out of 176 of patients (7%) a neoplasm was diagnosed. If additional diagnostic workup revealed an aetiology, the recurrence rate was lower in the treated patients than in the patients without a definite aetiology (15% versus 43%, p = 0.014). CONCLUSION Additional diagnostic testing revealed an aetiology in one-third of 'presumed' IAP patients. The aetiology found was mostly biliary, but occasionally neoplasms were found. Identification of an aetiology with subsequent treatment reduced the rate of recurrence.
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Affiliation(s)
- Nora D Hallensleben
- Department of Gastroenterology, Erasmus
MC University Medical Centre, Rotterdam, the Netherlands
- Department of Research and Development,
St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Devica S Umans
- Department of Research and Development,
St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Gastroenterology,
Amsterdam UMC, Amsterdam, the Netherlands
| | - Stefan AW Bouwense
- Department of Surgery, Radboud
University Medical Centre, Nijmegen, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology, St
Antonius Hospital, Nieuwegein, the Netherlands
| | - Tessa EH Romkens
- Department of Gastroenterology, Jeroen
Bosch Hospital, ‘s Hertogenbosch, the Netherlands
| | - Ben J Witteman
- Department of Gastroenterology, Gelderse
Vallei Hospital, Ede, the Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology, Meander
Medical Centre, Amersfoort, the Netherlands
| | - Marcel B Spanier
- Department of Gastroenterology,
Rijnstate Hospital, Arnhem, the Netherlands
| | - Robert Laheij
- Department of Gastroenterology, St.
Elisabeth – Tweesteden Hospital, Tilburg, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius
Hospital, Nieuwegein, the Netherlands
- Department of Surgery, University
Medical Centre, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC,
Amsterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology,
Amsterdam UMC, Amsterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology, Erasmus
MC University Medical Centre, Rotterdam, the Netherlands
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15
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Schulz C, Schirra J, Mayerle J. Indications for endoscopic retrograde cholangiopancreatography and cholecystectomy in biliary pancreatitis. Br J Surg 2019; 107:11-13. [PMID: 31869457 DOI: 10.1002/bjs.11402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 09/24/2019] [Indexed: 01/08/2023]
Affiliation(s)
- C Schulz
- Medical Department II, University Hospital, LMU, D-81377, Munich, Germany
| | - J Schirra
- Medical Department II, University Hospital, LMU, D-81377, Munich, Germany
| | - J Mayerle
- Medical Department II, University Hospital, LMU, D-81377, Munich, Germany
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16
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Halász A, Pécsi D, Farkas N, Izbéki F, Gajdán L, Fejes R, Hamvas J, Takács T, Szepes Z, Czakó L, Vincze Á, Gódi S, Szentesi A, Párniczky A, Illés D, Kui B, Varjú P, Márta K, Varga M, Novák J, Szepes A, Bod B, Ihász M, Hegyi P, Hritz I, Erőss B. Outcomes and timing of endoscopic retrograde cholangiopancreatography for acute biliary pancreatitis. Dig Liver Dis 2019; 51:1281-1286. [PMID: 31031177 DOI: 10.1016/j.dld.2019.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/20/2019] [Accepted: 03/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Indication of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis (ABP) is challenging. AIMS In this retrospective study, we analyzed real-world data to understand the ERCP practice in ABP in Hungarian centers. METHODS Clinical data on ABP patients (2013-2015) were extracted from our large multicentric database. Outcomes, quality indicators and the role of early timing of ERCP (<24 h from admission) were analyzed. RESULTS There were 356 patients with ABP. ERCP was performed in 267 (75%). Performance indicators of ERCP proved to be suboptimal with a biliary cannulation rate of 84%. Successful vs unsuccessful cannulation of naïve papilla resulted in lower rates of local [22.9% vs 40.9%, (P = 0.012)] and systemic [4.9% vs 13.6%, (P = 0.042)] complications. Successful vs unsuccessful clearance resulted in lower rates of local complications [22.5% vs 40.8%, (P = 0.008)]. Successful cannulation and drainage correlated with less severe course of ABP [3.6% vs 15.9%, (P = 0.001) and 4.1% vs 12.2%, (P = 0.033)] respectively. A tendency of an increased rate of local complications was observed if ERCP was performed later [<24 h: 21.1% (35/166); between 24-48 h: 23.4% (11/47); >48h: 37.2% (16/43) (P = 0.088)]. CONCLUSION Optimization of ERCP indication in ABP patients is critical as suboptimal ERCP practices in ABP without definitive stone detection are associated with poorer clinical outcomes.
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Affiliation(s)
- Adrienn Halász
- Szent György Teaching Hospital of Fejér County, Székesfehérvár, Hungary.
| | - Dániel Pécsi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.
| | - Nelli Farkas
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Institute of Bioanalysis and Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.
| | - Ferenc Izbéki
- Szent György Teaching Hospital of Fejér County, Székesfehérvár, Hungary.
| | - László Gajdán
- Szent György Teaching Hospital of Fejér County, Székesfehérvár, Hungary.
| | - Roland Fejes
- Szent György Teaching Hospital of Fejér County, Székesfehérvár, Hungary.
| | - József Hamvas
- Bajcsy-Zsilinszky Teaching Hospital of Semmelweis University, Budapest, Hungary.
| | - Tamás Takács
- First Department of Medicine, University of Szeged, Szeged, Hungary.
| | - Zoltán Szepes
- First Department of Medicine, University of Szeged, Szeged, Hungary.
| | - László Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary.
| | - Áron Vincze
- First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary.
| | - Szilárd Gódi
- First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary.
| | - Andrea Szentesi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; First Department of Medicine, University of Szeged, Szeged, Hungary.
| | | | - Dóra Illés
- First Department of Medicine, University of Szeged, Szeged, Hungary.
| | - Balázs Kui
- First Department of Medicine, University of Szeged, Szeged, Hungary.
| | - Péter Varjú
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.
| | - Katalin Márta
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.
| | - Márta Varga
- BMKK, Dr. Réthy Pál Hospital, Békéscsaba, Hungary.
| | - János Novák
- BMKK, Pándy Kálmán Hospital, Gyula, Hungary.
| | - Attila Szepes
- Bács-Kiskun County University Teaching Hospital, Kecskemét, Hungary.
| | - Barnabás Bod
- Dr. Bugyi István Hospital of Csongrád County, Szentes, Hungary.
| | - Miklós Ihász
- Markusovszky Teaching Hospital, Szombathely, Szombathely, Hungary.
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; First Department of Medicine, University of Pécs, Pécs, Hungary; MTA-SZTE Momentum Translational Gastroenterology Research Group, Szeged, Hungary.
| | - István Hritz
- First Department of Surgery, Center for Therapeutic Endoscopy, Semmelweis University, Budapest, Hungary.
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.
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17
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Abstract
The incidence of acute pancreatitis continues to increase worldwide, and it is one of the most common gastrointestinal causes for hospital admission in the USA. In the past decade, substantial advancements have been made in our understanding of the pathophysiological mechanisms of acute pancreatitis. Studies have elucidated mechanisms of calcium-mediated acinar cell injury and death and the importance of store-operated calcium entry channels and mitochondrial permeability transition pores. The cytoprotective role of the unfolded protein response and autophagy in preventing sustained endoplasmic reticulum stress, apoptosis and necrosis has also been characterized, as has the central role of unsaturated fatty acids in causing pancreatic organ failure. Characterization of these pathways has led to the identification of potential molecular targets for future therapeutic trials. At the patient level, two classification systems have been developed to classify the severity of acute pancreatitis into prognostically meaningful groups, and several landmark clinical trials have informed management strategies in areas of nutritional support and interventions for infected pancreatic necrosis that have resulted in important changes to acute pancreatitis management paradigms. In this Review, we provide a summary of recent advances in acute pancreatitis with a special emphasis on pathophysiological mechanisms and clinical management of the disorder.
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18
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Kucserik LP, Márta K, Vincze Á, Lázár G, Czakó L, Szentkereszty Z, Papp M, Palatka K, Izbéki F, Altorjay Á, Török I, Barbu S, Tantau M, Vereczkei A, Bogár L, Dénes M, Németh I, Szentesi A, Zádori N, Antal J, Lerch MM, Neoptolemos J, Sahin-Tóth M, Petersen OH, Kelemen D, Hegyi P. Endoscopic sphincterotoMy for delayIng choLecystectomy in mild acute biliarY pancreatitis (EMILY study): protocol of a multicentre randomised clinical trial. BMJ Open 2019; 9:e025551. [PMID: 31289058 PMCID: PMC6629406 DOI: 10.1136/bmjopen-2018-025551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION According to the literature, early cholecystectomy is necessary to avoid complications related to gallstones after an initial episode of acute biliary pancreatitis (ABP). A randomised, controlled multicentre trial (the PONCHO trial) revealed that in the case of gallstone-induced pancreatitis, early cholecystectomy was safe in patients with mild gallstone pancreatitis and reduced the risk of recurrent gallstone-related complications, as compared with interval cholecystectomy. We hypothesise that carrying out a sphincterotomy (ES) allows us to delay cholecystectomy, thus making it logistically easier to perform and potentially increasing the efficacy and safety of the procedure. METHODS/DESIGN EMILY is a prospective, randomised, controlled multicentre trial. All patients with mild ABP, who underwent ES during the index admission or in the medical history will be informed to take part in EMILY study. The patients will be randomised into two groups: (1) early cholecystectomy (within 6 days after discharge) and (2) patients with delayed (interval) cholecystectomy (between 45 and 60 days after discharge). During a 12-month period, 93 patients will be enrolled from participating clinics. The primary endpoint is a composite endpoint of mortality and recurrent acute biliary events (that is, recurrent ABP, acute cholecystitis, uncomplicated biliary colic and cholangitis). The secondary endpoints are organ failure, biliary leakage, technical difficulty of the cholecystectomy, surgical and other complications. ETHICS AND DISSEMINATION The trial has been registered internationally ISRCTN 10667869, and approved by the relevant organisation, the Scientific and Research Ethics Committee of the Hungarian Medical Research Council (EKU/2018/12176-5). TRIAL REGISTRATION NUMBER ISCRTN 10667869; Pre-results.
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Affiliation(s)
- Levente Pál Kucserik
- Division of Surgery, Universitatea de Medicina si Farmacie din Targu Mures, Targu Mures, Romania
| | - Katalin Márta
- Institute for Translational Medicine, Pecsi Tudomanyegyetem Altalanos Orvostudomanyi Kar, Pecs, Hungary
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Áron Vincze
- Institute for Translational Medicine, Pecsi Tudomanyegyetem Altalanos Orvostudomanyi Kar, Pecs, Hungary
- Division of Gastroenterology, First Department of Internal Medicine, Pecsi Tudomanyegyetem Altalanos Orvostudomanyi Kar, Pecs, Hungary
| | - György Lázár
- Department of Surgery, University of Szeged, Szeged, Hungary
| | - László Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | | | - Mária Papp
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Debreceni Egyetem, Debrecen, Hungary
| | - Károly Palatka
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Debreceni Egyetem, Debrecen, Hungary
| | - Ferenc Izbéki
- Divison of Gastroenterology, Fejer County Saint George Teaching Hospital of University of Pécs, Székesfehérvár, Hungary
| | - Áron Altorjay
- Division of Surgery, Fejer County Saint George Teaching Hospital of University of Pécs, Székesfehérvár, Hungary
| | - Imola Török
- Division of Gastroenterology, Universitatea de Medicina si Farmacie din Targu Mures, Targu Mures, Romania
| | - Sorin Barbu
- 4thSurgery Department, “Iuliu Hatieganu” University of Medicine & Pharmacy, Cluj-Napoca, Romania
| | - Marcel Tantau
- 4thSurgery Department, “Iuliu Hatieganu” University of Medicine & Pharmacy, Cluj-Napoca, Romania
| | - András Vereczkei
- Department for Surgery, Pecsi Tudomanyegyetem Altalanos Orvostudomanyi Kar, Pecs, Hungary
| | - Lajos Bogár
- Department of Anaesthesiology and Intensive Therapy, Pecsi Tudomanyegyetem Altalanos Orvostudomanyi Kar, Pecs, Hungary
| | - Márton Dénes
- Second Department of Surgery, County Hospital Targu Mures, Targu Mures, Romania
| | - Imola Németh
- Data-Management, Pre-Clinical and Clinical Biostatistics, Adware Research Developing and Consulting Ltd, Balatonfüred, Hungary
| | - Andrea Szentesi
- Institute for Translational Medicine, Pecsi Tudomanyegyetem, Pecs, Hungary
- MTA-SZTE Translational Gastroenterology Research Group, Szegedi Tudomanyegyetem, Szeged, Hungary
| | - Noémi Zádori
- Institute for Translational Medicine, Pecsi Tudomanyegyetem Altalanos Orvostudomanyi Kar, Pecs, Hungary
| | - Judit Antal
- Institute for Translational Medicine, Pecsi Tudomanyegyetem Altalanos Orvostudomanyi Kar, Pecs, Hungary
| | - Markus M Lerch
- Department of Medicine A, Universitatsmedizin Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany
| | - John Neoptolemos
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, Liverpool, UK
| | - Miklós Sahin-Tóth
- Department of Molecular and Cell Biology, Henry M. Goldman School of Dental Medicine, Boston University, Boston, MA 02118, USA
| | - Ole H Petersen
- School of Biosciences, Cardiff University, Cardiff, South Glamorgan, UK
| | - Dezső Kelemen
- Surgery Clinic, Pecsi Tudomanyegyetem, Pecs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Pecsi Tudomanyegyetem Altalanos Orvostudomanyi Kar, Pecs, Hungary
- MTA-SZTE, Translational Gastroenterology Research Group, Szeged, Hungary
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19
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Leppäniemi A, Tolonen M, Tarasconi A, Segovia-Lohse H, Gamberini E, Kirkpatrick AW, Ball CG, Parry N, Sartelli M, Wolbrink D, van Goor H, Baiocchi G, Ansaloni L, Biffl W, Coccolini F, Di Saverio S, Kluger Y, Moore E, Catena F. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg 2019; 14:27. [PMID: 31210778 PMCID: PMC6567462 DOI: 10.1186/s13017-019-0247-0] [Citation(s) in RCA: 332] [Impact Index Per Article: 66.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/27/2019] [Indexed: 02/08/2023] Open
Abstract
Although most patients with acute pancreatitis have the mild form of the disease, about 20-30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27-30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.
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Affiliation(s)
- Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital Meilahti, Haartmaninkatu 4, FI-00029 Helsinki,, Finland
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital Meilahti, Haartmaninkatu 4, FI-00029 Helsinki,, Finland
| | - Antonio Tarasconi
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | | | - Emiliano Gamberini
- Anesthesia and Intensive Care Medicine, Maurizio Bufalini Hospital, Cesena, Italy
| | | | - Chad G. Ball
- Foothills Medical Centre & the University of Calgary, Calgary, AB Canada
| | - Neil Parry
- London Health Sciences Centre, London, ON Canada
| | | | - Daan Wolbrink
- Radboud University Nijmegen, Nijmegen, The Netherlands
| | | | - Gianluca Baiocchi
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps memorial Hospital, La Jolla, CA USA
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest Moore
- Trauma Surgery, Denver Health Medical Center, Denver, CO USA
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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20
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Żorniak M, Beyer G, Mayerle J. Risk Stratification and Early Conservative Treatment of Acute Pancreatitis. Visc Med 2019; 35:82-89. [PMID: 31192241 PMCID: PMC6514505 DOI: 10.1159/000497290] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 01/28/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Acute pancreatitis (AP) is a potentially life-threatening common gastrointestinal disorder with increasing incidence around the globe. Although the majority of cases will take an uneventful, mild course, a fraction of patients is at risk of moderately severe or severe pancreatitis which is burdened with substantial morbidity and mortality. Early identification of patients at risk of a severe disease course and an adopted treatment strategy are crucial to avoid adverse outcomes. SUMMARY In this review we summarize the most recent concepts of severity grading in patients diagnosed with AP by adopting recommendations of current guidelines and discussing them in the context of the available literature. The severity of AP depends on the presence of local and/or systemic complications and organ failure. To predict the severity early in the disease course, host-specific factors (age, comorbidities, body mass index), clinical risk factors (biochemical and physiological parameters and scoring systems), as well as the response to initial therapy need to be considered and revisited in the short term. Depending on the individual risk and comorbidity the initial treatment can be guided, which will be discussed in the second part of this review. KEY MESSAGE Predicting the severity of AP and adapting the individual treatment strategy requires multidimensional risk assessment and close observation during the early phase of AP development.
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Affiliation(s)
- Michał Żorniak
- Department of Gastroenterology, Medical University of Silesia, Katowice, Poland
| | - Georg Beyer
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
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21
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Abstract
Acute pancreatitis is among the most common gastrointestinal disorders requiring hospitalization worldwide. Establishing the cause of acute pancreatitis ensures appropriate management and proper health care resource utilization. Causes of acute pancreatitis include biliary, alcohol use, hypertriglyceridemia, hypercalcemia, drug-induced, autoimmune, hereditary/genetic, and anatomic abnormalities. Fluid therapy remains the cornerstone of managing acute pancreatitis. This article provides a brief summary of current evidence-based practices in the diagnosis and management of uncomplicated acute pancreatitis.
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23
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Early Endoscopic Retrograde Cholangiopancreatography Versus Conservative Treatment in Patients With Acute Biliary Pancreatitis: Systematic Review and Meta-analysis of Randomized Controlled Trials. Pancreas 2018. [PMID: 29517637 DOI: 10.1097/mpa.0000000000001032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate the role of early endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of acute biliary pancreatitis, in comparison with conservative treatment. METHODS Systematic review via databases (MEDLINE [PubMed], Latin-American and Caribbean Health Sciences Literature database, Embase, Cochrane Central, and the [Brazilian] Regional Library of Medicine) is conducted. We analyzed 10 randomized controlled trials (1091 patients). Outcomes were the following: local and systemic adverse events; acute cholangitis; death; length of hospital stay; cost; abdominal pain; and time to a reduction in body temperature. For the meta-analysis, we used risk difference (RD) and mean with standard deviation as measures of variability. RESULTS There was a statistically significant difference between the patients submitted to ERCP in terms of the following: local adverse events (RD, 0.74; 95% confidence interval [CI], 0.55-0.99), time to pain relief and time to a reduction in axillary temperature (RD, -5.01; 95% CI, -6.98 to -3.04, and RD, -1.70; 95 CI%, -2.33 to -1.08, respectively). Patients undergoing ERCP spent less time in hospital (RD, -11.04; 95% CI, -15.15 to -6.93). Cost was lower in the group treated with ERCP. CONCLUSIONS Early ERCP decreases local adverse events, shortening the time to pain relief, to a reduction in axillary temperature, hospital stays, and cost in patients with acute biliary pancreatitis.
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van Dijk SM, Hallensleben NDL, van Santvoort HC, Fockens P, van Goor H, Bruno MJ, Besselink MG. Acute pancreatitis: recent advances through randomised trials. Gut 2017; 66:2024-2032. [PMID: 28838972 DOI: 10.1136/gutjnl-2016-313595] [Citation(s) in RCA: 241] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/05/2017] [Accepted: 07/07/2017] [Indexed: 12/19/2022]
Abstract
Acute pancreatitis is one of the most common GI conditions requiring acute hospitalisation and has a rising incidence. In recent years, important insights on the management of acute pancreatitis have been obtained through numerous randomised controlled trials. Based on this evidence, the treatment of acute pancreatitis has gradually developed towards a tailored, multidisciplinary effort, with distinctive roles for gastroenterologists, radiologists and surgeons. This review summarises how to diagnose, classify and manage patients with acute pancreatitis, emphasising the evidence obtained through randomised controlled trials.
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Affiliation(s)
- Sven M van Dijk
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Academic Medical Center, Amsterdam, The Netherlands
| | - Nora D L Hallensleben
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, Academic Medical Center, Amsterdam, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Academic Medical Center, Amsterdam, The Netherlands
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