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Trikudanathan G, Yazici C, Evans Phillips A, Forsmark CE. Diagnosis and Management of Acute Pancreatitis. Gastroenterology 2024; 167:673-688. [PMID: 38759844 DOI: 10.1053/j.gastro.2024.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 01/03/2024] [Accepted: 02/18/2024] [Indexed: 05/19/2024]
Abstract
Acute pancreatitis (AP) is increasing in incidence across the world, and in all age groups. Major changes in management have occurred in the last decade. Avoiding total parenteral nutrition and prophylactic antibiotics, avoiding overly aggressive fluid resuscitation, initiating early feeding, avoiding endoscopic retrograde cholangiopancreatography in the absence of concomitant cholangitis, same-admission cholecystectomy, and minimally invasive approaches to infected necrosis should now be standard of care. Increasing recognition of the risk of recurrence of AP, and progression to chronic pancreatitis, along with the unexpectedly high risk of diabetes and exocrine insufficiency after AP is the subject of large ongoing studies. In this review, we provide an update on important changes in management for this increasingly common disease.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Cemal Yazici
- Division of Gastroenterology and Hepatology, University of Illinois, Chicago, Illinois
| | - Anna Evans Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida.
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Campillo Arregui A, Bolado Concejo F, León Brito H, Martínez-Acítores de la Mata D, Ubieto Capela V, Cebrián García A, Kutz Leoz M, Laiglesia Izquierdo M. Management of analgesia in acute pancreatitis: Results of a national survey. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:230-235. [PMID: 37207963 DOI: 10.1016/j.gastrohep.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/24/2023] [Accepted: 05/08/2023] [Indexed: 05/21/2023]
Abstract
INTRODUCTION Acute pancreatitis is one of the main reasons for digestive admissions. Adequate pain treatment is crucial in its management. However, there are hardly any descriptions of the analgesic guidelines used in our setting. METHODS On-line survey on analgesic management in acute pancreatitis, aimed at attending physicians and residents practising in Spain. RESULTS Two hundred and nine physicians from 88 centres responded to the survey. Ninety percent were specialists in gastrointestinal medicine and 69% worked in a tertiary centre. The majority (64.4%) do not routinely use scales to measure pain. When choosing a drug, experience in its use was the most important factor. The most commonly prescribed initial treatments are: combination of paracetamol and metamizole (53.5%), paracetamol alone (19.1%) and metamizole alone (17.4%). As rescue: meperidine (54.8%), tramadol (17.8%), morphine chloride (17.8%) and metamizole (11.5%). Continuous perfusion is used in 8.2% of initial treatments. Physicians with >10 years of service use more metamizole as monotherapy (50%), while residents and attending physicians with <10 years of service prescribe it in combination with paracetamol (85%). If progression is needed, morphine chloride and meperidine are mainly used. The speciality of the respondent, the size of the work centre and the unit/service where the patients were admitted did not influence the analgesia prescribed. Satisfaction with pain management reached 7.8/10 (SD 0.98). CONCLUSION In our setting, metamizole and paracetamol are the most commonly used analgesics as initial pain treatment in acute pancreatitis, and meperidine is the most commonly used rescue analgesic.
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Affiliation(s)
| | - Federico Bolado Concejo
- Servicio de Aparato Digestivo, Hospital Universitario de Navarra, Pamplona, España; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, España.
| | - Helena León Brito
- Unidad de Aparato Digestivo, Hospital Reina Sofía, Tudela de Navarra, España
| | | | | | - Alba Cebrián García
- Unidad de Aparato Digestivo, Hospital Reina Sofía, Tudela de Navarra, España
| | - Marcos Kutz Leoz
- Unidad de Aparato Digestivo, Hospital Reina Sofía, Tudela de Navarra, España
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Huang Y, Badurdeen DS. Acute Pancreatitis Review. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2023; 34:795-801. [PMID: 37404118 PMCID: PMC10544623 DOI: 10.5152/tjg.2023.23175] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/05/2023] [Indexed: 07/06/2023]
Abstract
Acute pancreatitis, a prevalent illness with devastating consequences, poses a grave threat to those affected. There has been a steady increase in the occurrence of acute pancreatitis at about 3% per year from 1961 to 2016. There are 3 main guidelines on acute pancreatitis, including the American College of Gastroenterology, the International Association of Pancreatology/American Pancreatic Association guideline in 2013, and the American Gastroenterological Association guideline in 2018. However, several milestone studies have been published since then. We hereby reviewed the current acute pancreatitis guidelines with an update on clinical practicechanging literature. The aggressive or moderate fluid resuscitation in acute pancreatitis (WATERFALL) trial recommended fluid resuscitation with lactated Ringer's solution at a moderate aggressive rate. All guidelines did not recommend prophylactic antibiotics use. Early enteral feeding reduces morbidity. A clear liquid diet is no longer recommended. Nutrition with nasogastric or nasojejunal feeding does not have a difference. The upcoming high vs. low-energy administration in the early phase of acute pancreatitis (GOULASH) trial will provide more information on the impact of calorie intake. Pain management should be individualized based on the degree of pain and severity of pancreatitis. In patients with moderate to severe and severe acute pancreatitis, a step-down approach with epidural analgesia can be considered for moderate to severe pain. The management of acute pancreatitis has evolved. New research on the impact of electrolytes, pharmacologic agents, the role of anticoagulants, and nutrition support will provide scientific and clinical evidence to improve patient care and decrease morbidity and mortality.
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Affiliation(s)
- Yuting Huang
- Department of Gastroenterology and Hepatology, Mayo Clinic, FL, USA
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Jabaudon M, Genevrier A, Jaber S, Windisch O, Bulyez S, Laterre PF, Escudier E, Sossou A, Guerci P, Bertrand PM, Danin PE, Bonnassieux M, Bühler L, Heidegger CP, Chabanne R, Godet T, Roszyk L, Sapin V, Futier E, Pereira B, Constantin JM. Thoracic epidural analgesia in intensive care unit patients with acute pancreatitis: the EPIPAN multicenter randomized controlled trial. Crit Care 2023; 27:213. [PMID: 37259157 DOI: 10.1186/s13054-023-04502-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/20/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Findings from preclinical studies and one pilot clinical trial suggest potential benefits of epidural analgesia in acute pancreatitis. We aimed to assess the efficacy of thoracic epidural analgesia, in addition to usual care, in improving clinical outcomes of intensive care unit patients with acute pancreatitis. METHODS A multicenter, open-label, randomized, controlled trial including adult patients with a clinical diagnosis of acute pancreatitis upon admission to the intensive care unit. Participants were randomly assigned (1:1) to a strategy combining thoracic epidural analgesia and usual care (intervention group) or a strategy of usual care alone (control group). The primary outcome was the number of ventilator-free days from randomization until day 30. RESULTS Between June 2014 and January 2019, 148 patients were enrolled, and 135 patients were included in the intention-to-treat analysis, with 65 patients randomly assigned to the intervention group and 70 to the control group. The number of ventilator-free days did not differ significantly between the intervention and control groups (median [interquartile range], 30 days [15-30] and 30 days [18-30], respectively; median absolute difference of - 0.0 days, 95% CI - 3.3 to 3.3; p = 0.59). Epidural analgesia was significantly associated with longer duration of invasive ventilation (median [interquartile range], 14 days [5-28] versus 6 days [2-13], p = 0.02). CONCLUSIONS In a population of intensive care unit adults with acute pancreatitis and low requirement for intubation, this first multicenter randomized trial did not show the hypothesized benefit of epidural analgesia in addition to usual care. Safety of epidural analgesia in this setting requires further investigation. TRIAL REGISTRATION ClinicalTrials.gov registration number NCT02126332 , April 30, 2014.
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Affiliation(s)
- Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France.
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France.
| | - Alexandra Genevrier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Samir Jaber
- Saint Eloi Intensive Care Unit, CHU Montpellier, Montpellier, France
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Olivier Windisch
- Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Stéphanie Bulyez
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
- Service de Recherche Clinique en Soins Critiques, Pôle Anesthésie Douleur Urgences Réanimation, CHU Nîmes, Université de Montpellier, Nîmes, France
| | - Pierre-François Laterre
- Department of Critical Care Medicine, Saint Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Etienne Escudier
- Department of Emergency Medicine and Intensive Care, Annecy Genevois General Hospital, Annecy, France
| | - Achille Sossou
- Department of Intensive Care Medicine, Emile-Roux General Hospital, Le Puy-en-Velay, France
| | - Philippe Guerci
- Department of Anesthesiology and Critical Care Medicine, CHU Nancy-Brabois, Nancy, France
- Institut Lorrain du Coeur Et Des Vaisseaux and INSERM U1116, Institut Lorrain du Coeur et des Vaisseaux, University of Lorraine, Nancy, France
| | | | - Pierre-Eric Danin
- Department of Intensive Care Medicine, CHU Nice, Nice, France
- INSERM U1065, Team 8, C3M, CHU de Nice, Nice, France
| | - Martin Bonnassieux
- Department of Intensive Care Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Leo Bühler
- Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Claudia Paula Heidegger
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Russell Chabanne
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Thomas Godet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Laurence Roszyk
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- Department of Biochemistry and Molecular Genetics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Vincent Sapin
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- Department of Biochemistry and Molecular Genetics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics and Data Management Unit, Department of Clinical Research and Innovation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Department of Anesthesiology and Critical Care, GRC 29, DMU DREAM, Pitié-Salpêtrière Hospital, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Paris, France
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Manrai M, Dawra S, Singh AK, Jha DK, Kochhar R. Controversies in the management of acute pancreatitis: An update. World J Clin Cases 2023; 11:2582-2603. [PMID: 37214572 PMCID: PMC10198120 DOI: 10.12998/wjcc.v11.i12.2582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/22/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023] Open
Abstract
This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.
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Affiliation(s)
- Manish Manrai
- Department of Internal Medicine, Armed Forces Medical College, Pune 411040, India
| | - Saurabh Dawra
- Department of Medicine and Gastroenterology, Command Hospital, Pune 411040, India
| | - Anupam K Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Daya Krishna Jha
- Department of Gastroenterology, Army Hospital (Research and Referral), New Delhi 11010, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Al-Leswas D, Baxter N, Lim WB, Robertson F, Ratnayake B, Samanta J, Capurso G, de-Madaria E, Drewes AM, Windsor J, Pandanaboyana S. The safety and efficacy of epidural anaesthesia in acute pancreatitis: a systematic review and meta-analysis. HPB (Oxford) 2023; 25:162-171. [PMID: 36593161 DOI: 10.1016/j.hpb.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/02/2022] [Accepted: 12/09/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Acute pancreatitis (AP) has variable clinical courses. This systematic review and meta-analysis aimed to determine the safety, efficacy, and impact of epidural anaesthesia (EA) use in AP. METHODS The PubMed, EMBASE, SCOPUS and Cochrane library databases were systematically searched between 1980 and 2022 using the PRISMA guidelines, to identify observational and comparative studies reporting on EA in AP. The meta-analysis was performed in R Foundation for Statistical Computing using the meta R Package for Meta-Analysis. RESULTS A total of 9 studies with 2006 patients of which 726 (36%) patients had EA were included. All studies demonstrated high safety and feasibility of EA in AP with no reported major local or neurological complications. One randomised controlled trial demonstrated an improvement in pain severity using a 0-10 visual analogue scale (VAS) at the outset (1.6 in EA vs 3.5 in non-EA, P = 0.02) and on day 10 (0.2 in EA vs 2.33 in non-EA, P = 0.034). There was also improvement in pancreatic perfusion with EA measured with computerised tomography 13 (43%) in EA vs 2 (7%) in non-EA, P = 0.003. The need for ventilatory support and overall mortality was lower in EA patients 40 (19%) vs 285 (24%) P = 0.025 (OR: 0.49, 95% CI: 0.28-0.84) and 16 (7%) vs 214 (20%), P = 0.050 (OR: 0.39, 95% CI: 0.15-1.00), respectively. CONCLUSION EA is infrequently used for pain management in AP and yet the available evidence suggests that it is safe and effective in reducing pain severity, improving pancreatic perfusion, and decreasing mortality.
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Affiliation(s)
- Dhya Al-Leswas
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Nesta Baxter
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Wei B Lim
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Francis Robertson
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | | | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gabriele Capurso
- Pancreatico-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Enrique de-Madaria
- Gastroenterology Department, Dr. Balmis General University Hospital; Department of Clinical Medicine, Miguel Hernández University; ISABIAL, Alicante, Spain
| | - Asbjørn M Drewes
- Department of Gastroenterology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - John Windsor
- HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand; Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Sanjay Pandanaboyana
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK; Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK.
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Jaber S, Garnier M, Asehnoune K, Bounes F, Buscail L, Chevaux JB, Dahyot-Fizelier C, Darrivere L, Jabaudon M, Joannes-Boyau O, Launey Y, Levesque E, Levy P, Montravers P, Muller L, Rimmelé T, Roger C, Savoye-Collet C, Seguin P, Tasu JP, Thibault R, Vanbiervliet G, Weiss E, Jong AD. Pancréatite aiguë grave du patient adulte en soins critiques 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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8
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Update on pain management in acute pancreatitis. Curr Opin Gastroenterol 2022; 38:487-494. [PMID: 35894669 DOI: 10.1097/mog.0000000000000861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Chen Z, Jiang K, Liu F, Zhu P, Cai F, He Y, Jin T, Lin Z, Li Q, Hu C, Tan Q, Yang X, Guo J, Huang W, Deng L, Xia Q. Safety and efficacy of intravenous hydromorphone patient-controlled analgesia versus intramuscular pethidine in acute pancreatitis: An open-label, randomized controlled trial. Front Pharmacol 2022; 13:962671. [PMID: 35991892 PMCID: PMC9387897 DOI: 10.3389/fphar.2022.962671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Hydromorphone patient-controlled analgesia (PCA) provides satisfactory postoperative pain therapy, but its effect has not been assessed in acute pancreatitis (AP).Aim: To assess the safety and efficacy of intravenous hydromorphone PCA for pain relief in AP.Methods: This open-label trial included AP patients admitted within 72 h of symptom onset, aged 18–70 years old, and with Visual Analog Scale (VAS) for pain intensity ≥5. They were randomized to receive intravenous hydromorphone PCA (0.05 mg/h with 0.2 mg on-demand) or intramuscular pethidine (50 mg as required) for three consecutive days. Intramuscular dezocine (5 mg on demand) was the rescue analgesia. The primary outcome was the change of VAS score recorded every 4 h for 3 days. Interim analysis was conducted by an Independent Data and Safety Monitoring Committee (IDSMC).Results: From 26 July 2019 to 15 January 2020, 77 patients were eligible for the intention-to-treat analysis in the interim analysis (39 in the hydromorphone group and 38 in the pethidine group). Baseline parameters were comparable between groups. No difference in VAS between the two groups was found. Hydromorphone PCA was associated with higher moderately severe to severe cases (82.1% vs. 55.3%, p = 0.011), acute peripancreatic fluid collections (53.9% vs. 28.9%, p = 0.027), more cumulative opioid consumption (median 46.7 vs. 5 mg, p < 0.001), higher analgesia costs (median 85.5 vs. 0.5 $, p < 0.001) and hospitalization costs (median 3,778 vs. 2,273 $, p = 0.007), and more adverse events (20.5% vs. 2.6%, p = 0.087). The per-protocol analysis did not change the results. Although a sample size of 122 patients was planned, the IDSMC halted further recruitment as disease worsening or worse clinical outcomes between the groups in the interim analysis.Conclusion: Hydromorphone PCA was not superior to pethidine in relieving pain in AP patients and might have worse clinical outcomes. Therefore, its use is not recommended.Clinical Trial Registration: Chictr.org.cn. ChiCTR1900025971
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Affiliation(s)
- Zhiyao Chen
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Kun Jiang
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Zhu
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Cai
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yanqiu He
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Jin
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Ziqi Lin
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qian Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Cheng Hu
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qingyuan Tan
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaonan Yang
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jia Guo
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wei Huang, ; Lihui Deng, ; Qing Xia,
| | - Lihui Deng
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wei Huang, ; Lihui Deng, ; Qing Xia,
| | - Qing Xia
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wei Huang, ; Lihui Deng, ; Qing Xia,
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10
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Thoracic Epidural Analgesia in Acute Pancreatitis: A Systematic Review. Pancreas 2022; 51:e95-e97. [PMID: 36395413 DOI: 10.1097/mpa.0000000000002111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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11
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Thavanesan N, Pandanaboyana S. Author's Reply: Analgesia in the Initial Management of Acute Pancreatitis-A Systematic Review and Meta-Analysis of Randomized Controlled Trials. World J Surg 2022; 46:2014-2015. [PMID: 35665834 DOI: 10.1007/s00268-022-06611-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2022] [Indexed: 01/09/2023]
Affiliation(s)
| | - Sanjay Pandanaboyana
- HPB and Transplant Unit, Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK. .,Population Health Sciences Institute, Newcastle University, Newcastle, UK.
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Jaber S, Garnier M, Asehnoune K, Bounes F, Buscail L, Chevaux JB, Dahyot-Fizelier C, Darrivere L, Jabaudon M, Joannes-Boyau O, Launey Y, Levesque E, Levy P, Montravers P, Muller L, Rimmelé T, Roger C, Savoye-Collet C, Seguin P, Tasu JP, Thibault R, Vanbiervliet G, Weiss E, De Jong A. Guidelines for the management of patients with severe acute pancreatitis, 2021. Anaesth Crit Care Pain Med 2022; 41:101060. [PMID: 35636304 DOI: 10.1016/j.accpm.2022.101060] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To provide guidelines for the management of the intensive care patient with severe acute pancreatitis. DESIGN A consensus committee of 22 experts was convened. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS The most recent SFAR and SNFGE guidelines on the management of the patient with severe pancreatitis were published in 2001. The literature now is sufficient for an update. The committee studied 14 questions within 3 fields. Each question was formulated in a PICO (Patients Intervention Comparison Outcome) format and the relevant evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and their application of the GRADE® method resulted in 24 recommendations. Among the formalised recommendations, 8 have high levels of evidence (GRADE 1+/-) and 12 have moderate levels of evidence (GRADE 2+/-). For 4 recommendations, the GRADE method could not be applied, resulting in expert opinions. Four questions did not find any response in the literature. After one round of scoring, strong agreement was reached for all the recommendations. CONCLUSIONS There was strong agreement among experts for 24 recommendations to improve practices for the management of intensive care patients with severe acute pancreatitis.
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Affiliation(s)
- Samir Jaber
- Department of Anaesthesiology and Intensive Care (DAR B), University Hospital Center Saint Eloi Hospital, Montpellier, France; PhyMedExp, Montpellier University, INSERM, CNRS, CHU de Montpellier, Montpellier, France.
| | - Marc Garnier
- Sorbonne Université, GRC 29, DMU DREAM, Service d'Anesthésie-Réanimation et Médecine Périopératoire Rive Droite, Paris, France
| | - Karim Asehnoune
- Service d'Anesthésie, Réanimation chirurgicale, Hôtel Dieu/HME, CHU Nantes, Nantes cedex 1, France; Inserm, UMR 1064 CR2TI, team 6, France
| | - Fanny Bounes
- Toulouse University Hospital, Anaesthesia Critical Care and Perioperative Medicine Department, Toulouse, France; Équipe INSERM Pr Payrastre, I2MC, Université Paul Sabatier Toulouse III, Toulouse, France
| | - Louis Buscail
- Department of Gastroenterology & Pancreatology, University of Toulouse, Rangueil Hospital, Toulouse, France
| | | | - Claire Dahyot-Fizelier
- Anaesthesiology and Intensive Care Department, University hospital of Poitiers, Poitiers, France; INSERM U1070, University of Poitiers, Poitiers, France
| | - Lucie Darrivere
- Department of Anaesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, F-75010, Paris, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; iGReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France
| | - Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation SUD, CHU de Bordeaux, Hôpital Magellan, Bordeaux, France
| | - Yoann Launey
- Critical Care Unit, Department of Anaesthesia, Critical Care and Perioperative Medicine, University Hospital of Rennes, Rennes, France
| | - Eric Levesque
- Department of Anaesthesia and Surgical Intensive Care, AP-HP, Henri Mondor Hospital, Créteil, France; Université Paris-Est Creteil, EnvA, DYNAMiC, Faculté de Santé de Créteil, Creteil, France
| | - Philippe Levy
- Service de Pancréatologie et d'Oncologie Digestive, DMU DIGEST, Université de Paris, Hôpital Beaujon, APHP, Clichy, France
| | - Philippe Montravers
- Université de Paris Cité, INSERM UMR 1152 - PHERE, Paris, France; Département d'Anesthésie-Réanimation, APHP, CHU Bichat-Claude Bernard, DMU PARABOL, APHP, Paris, France
| | - Laurent Muller
- Réanimations et surveillance continue, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes Caremeau, Montpellier, France
| | - Thomas Rimmelé
- Département d'anesthésie-réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France; EA 7426: Pathophysiology of Injury-induced Immunosuppression, Pi3, Hospices Civils de Lyon-Biomérieux-Université Claude Bernard Lyon 1, Lyon, France
| | - Claire Roger
- Réanimations et surveillance continue, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes Caremeau, Montpellier, France; Department of Intensive care medicine, Division of Anaesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Céline Savoye-Collet
- Department of Radiology, Normandie University, UNIROUEN, Quantif-LITIS EA 4108, Rouen University Hospital-Charles Nicolle, Rouen, France
| | - Philippe Seguin
- Service d'Anesthésie Réanimation 1, Réanimation chirurgicale, CHU de Rennes, Rennes, France
| | - Jean-Pierre Tasu
- Service de radiologie diagnostique et interventionnelle, CHU de Poitiers, Poitiers, France; LaTim, UBO and INSERM 1101, University of Brest, Brest, France
| | - Ronan Thibault
- Service Endocrinologie-Diabétologie-Nutrition, CHU Rennes, INRAE, INSERM, Univ Rennes, NuMeCan, Nutrition Metabolisms Cancer, Rennes, France
| | - Geoffroy Vanbiervliet
- Department of Digestive Endoscopy, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France; University of Paris, Paris, France; Inserm UMR_S1149, Centre for Research on Inflammation, Paris, France
| | - Audrey De Jong
- Department of Anaesthesiology and Intensive Care (DAR B), University Hospital Center Saint Eloi Hospital, Montpellier, France; PhyMedExp, Montpellier University, INSERM, CNRS, CHU de Montpellier, Montpellier, France
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13
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Nair A, Tiwary MK, Seelam S, Kothapalli KK, Pulipaka K. Efficacy and Safety of Thoracic Epidural Analgesia in Patients With Acute Pancreatitis: A Narrative Review. Cureus 2022; 14:e23234. [PMID: 35449658 PMCID: PMC9012692 DOI: 10.7759/cureus.23234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/09/2022] Open
Abstract
Patients admitted to the intensive care unit with moderate to severe acute pancreatitis carry significant morbidity and mortality. A few unfortunate patients in whom the initial line of treatment fails to show clinical improvement develop multiorgan dysfunction involving lungs (adult respiratory distress syndrome), renal failure, intra-abdominal infections, sepsis, and septic shock, which ultimately leads to prolonged hospitalization and a substantial cost of treatment. The acute abdominal pain experienced by these patients is excruciating and requires multimodal analgesia. Continuous epidural analgesia has been found to provide good quality, opioid-sparing analgesia in these patients. A few studies have also demonstrated that segmental sympathectomy resulting from epidural blockade could lead to lowering of serum amylase and lipase levels improve paralytic ileus, and thus hastens the process of recovery. The present paper aims to discuss the advantages of continuous epidural analgesia in patients with acute pancreatitis of varying severity and to review the existing literature using specific keywords.
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Bálint ER, Fűr G, Kui B, Balla Z, Kormányos ES, Orján EM, Tóth B, Horváth G, Szűcs E, Benyhe S, Ducza E, Pallagi P, Maléth J, Venglovecz V, Hegyi P, Kiss L, Rakonczay Z. Fentanyl but Not Morphine or Buprenorphine Improves the Severity of Necrotizing Acute Pancreatitis in Rats. Int J Mol Sci 2022; 23:1192. [PMID: 35163111 PMCID: PMC8835441 DOI: 10.3390/ijms23031192] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 01/14/2022] [Accepted: 01/18/2022] [Indexed: 02/07/2023] Open
Abstract
Opioids are widely used for the pain management of acute pancreatitis (AP), but their impact on disease progression is unclear. Therefore, our aim was to study the effects of clinically relevant opioids on the severity of experimental AP. Various doses of fentanyl, morphine, or buprenorphine were administered as pre- and/or post-treatments in rats. Necrotizing AP was induced by the intraperitoneal injection of L-ornithine-HCl or intra-ductal injection of Na-taurocholate, while intraperitoneal caerulein administration caused edematous AP. Disease severity was determined by laboratory and histological measurements. Mu opioid receptor (MOR) expression and function was assessed in control and AP animals. MOR was expressed in both the pancreas and brain. The pancreatic expression and function of MOR were reduced in AP. Fentanyl post-treatment reduced necrotizing AP severity, whereas pre-treatment exacerbated it. Fentanyl did not affect the outcome of edematous AP. Morphine decreased vacuolization in edematous AP, while buprenorphine pre-treatment increased pancreatic edema during AP. The overall effects of morphine on disease severity were negligible. In conclusion, the type, dosing, administration route, and timing of opioid treatment can influence the effects of opioids on AP severity. Fentanyl post-treatment proved to be beneficial in AP. Clinical studies are needed to determine which opioids are best in AP.
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Affiliation(s)
- Emese Réka Bálint
- Department of Pathophysiology, University of Szeged, 6725 Szeged, Hungary; (E.R.B.); (G.F.); (Z.B.); (E.S.K.); (E.M.O.); (B.T.)
| | - Gabriella Fűr
- Department of Pathophysiology, University of Szeged, 6725 Szeged, Hungary; (E.R.B.); (G.F.); (Z.B.); (E.S.K.); (E.M.O.); (B.T.)
| | - Balázs Kui
- Department of Medicine, University of Szeged, 6725 Szeged, Hungary; (B.K.); (P.P.); (J.M.); (P.H.)
| | - Zsolt Balla
- Department of Pathophysiology, University of Szeged, 6725 Szeged, Hungary; (E.R.B.); (G.F.); (Z.B.); (E.S.K.); (E.M.O.); (B.T.)
| | - Eszter Sára Kormányos
- Department of Pathophysiology, University of Szeged, 6725 Szeged, Hungary; (E.R.B.); (G.F.); (Z.B.); (E.S.K.); (E.M.O.); (B.T.)
| | - Erik Márk Orján
- Department of Pathophysiology, University of Szeged, 6725 Szeged, Hungary; (E.R.B.); (G.F.); (Z.B.); (E.S.K.); (E.M.O.); (B.T.)
| | - Brigitta Tóth
- Department of Pathophysiology, University of Szeged, 6725 Szeged, Hungary; (E.R.B.); (G.F.); (Z.B.); (E.S.K.); (E.M.O.); (B.T.)
| | - Gyöngyi Horváth
- Department of Physiology, University of Szeged, 6725 Szeged, Hungary;
| | - Edina Szűcs
- Institute of Biochemistry, Biological Research Center, 6726 Szeged, Hungary; (E.S.); (S.B.)
| | - Sándor Benyhe
- Institute of Biochemistry, Biological Research Center, 6726 Szeged, Hungary; (E.S.); (S.B.)
| | - Eszter Ducza
- Department of Pharmacodynamics and Biopharmacy, Faculty of Pharmacy, University of Szeged, 6725 Szeged, Hungary;
| | - Petra Pallagi
- Department of Medicine, University of Szeged, 6725 Szeged, Hungary; (B.K.); (P.P.); (J.M.); (P.H.)
| | - József Maléth
- Department of Medicine, University of Szeged, 6725 Szeged, Hungary; (B.K.); (P.P.); (J.M.); (P.H.)
| | - Viktória Venglovecz
- Department of Pharmacology and Pharmacotherapy, University of Szeged, 6725 Szeged, Hungary;
| | - Péter Hegyi
- Department of Medicine, University of Szeged, 6725 Szeged, Hungary; (B.K.); (P.P.); (J.M.); (P.H.)
- Institute for Translational Medicine, Medical School, University of Pecs, 7624 Pecs, Hungary
| | - Lóránd Kiss
- Department of Pathophysiology, University of Szeged, 6725 Szeged, Hungary; (E.R.B.); (G.F.); (Z.B.); (E.S.K.); (E.M.O.); (B.T.)
| | - Zoltán Rakonczay
- Department of Pathophysiology, University of Szeged, 6725 Szeged, Hungary; (E.R.B.); (G.F.); (Z.B.); (E.S.K.); (E.M.O.); (B.T.)
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15
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Analgesia in the Initial Management of Acute Pancreatitis: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. World J Surg 2022; 46:878-890. [PMID: 34994837 DOI: 10.1007/s00268-021-06420-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimal analgesic strategy for patients with acute pancreatitis (AP) remains unknown. OBJECTIVE The present systematic review and meta-analysis aims to compare the efficacy of different analgesic modalities trialled in AP. METHODS A systematic search of PubMed, MEDLINE, EMBASE, CENTRAL, SCOPUS and Web of Science conducted up until June 2021, identified all randomised control trials (RCTs) comparing analgesic modalities in AP. A pooled analysis was undertaken of the improvement in pain scores as reported on visual analogue scale (VAS) on day 0, day 1 and day 2. RESULTS Twelve RCTs were identified including 542 patients. Seven trial drugs were compared: opiates, non-steroidal anti-inflammatories (NSAIDs), metamizole, local anaesthetic, epidural, paracetamol, and placebo. Across all modalities, the pooled VAS scores showed global improvement from baseline to day 2. Epidural analgesia appears to provide the greatest improvement in VAS within the first 24 h but is equivalent to opiates by 48 h. Within 24 h, NSAIDs offered similar pain-relief to opiates, while placebo also showed equivalence to other modalities but then plateaued. Local anaesthetics demonstrated least overall efficacy. VAS scores for opiate and non-opiate analgesics were comparable at baseline and day 1. The identified RCTs demonstrated significant statistical and methodological heterogeneity in pain-relief reporting. CONCLUSIONS There is remarkable paucity of level 1 evidence to guide pain management in AP with small datasets per study. Epidural administration appears effective within the first 24 h of AP although infrequently used and featured in only a single RCT. NSAIDs are an effective opiate sparing alternative during the first 24 h.
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16
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Cai W, Liu F, Wen Y, Han C, Prasad M, Xia Q, Singh VK, Sutton R, Huang W. Pain Management in Acute Pancreatitis: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Front Med (Lausanne) 2022; 8:782151. [PMID: 34977084 PMCID: PMC8718672 DOI: 10.3389/fmed.2021.782151] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/15/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Pain management is an important priority in the treatment of acute pancreatitis (AP). Current evidence and guideline recommendations are inconsistent on the most effective analgesic protocol. This systematic review and meta-analysis of randomised controlled trials (RCTs) aimed to compare the safety and efficacy of analgesics for pain relief in AP. Methods: A literature search was performed to identify all RCTs assessing analgesics in patients with AP. The primary outcome was the number of participants who needed rescue analgesia. Study quality was assessed using Jadad score. Pooled odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CI) were analysed using a random-effects model. Results: Twelve studies comprising 699 patients with AP (83% mild AP) were analysed. The tested analgesics significantly decreased the need for rescue analgesia (3 studies, OR.36, 95% CI 0.21 to 0.60) vs. placebo or conventional treatment. The analgesics also improved the pain score [Visual Analogue Scale (Δ-VAS)] at 24 h (WMD 18.46, 0.84 to 36.07) and by the 3rd to 7th days (WMD 11.57, 0.87 to 22.28). Opioids vs. non-opioids were associated with a decrease in the need for rescue analgesia (6 studies, OR 0.25, 95% CI 0.07 to 0.86, p = 0.03) but without significance in pain score. In subgroup analyses, opioids were similar to non-steroidal anti-inflammatory drugs (NSAIDs) regarding the primary outcome (4 studies, OR 0.56, 95% CI 0.24 to 1.32, p = 0.18). There were no significant differences in other clinical outcomes and rate of adverse events. Other studies, comparing epidural anaesthesia vs. patient-controlled analgesia and opioid (buprenorphine) vs. opioid (pethidine) did not show significant difference in primary outcome. Study quality issues significantly contributed to overall study heterogeneity. Conclusions: NSAIDs and opioids are equally effective in decreasing the need for rescue analgesia in patients with mild AP. The relative paucity of trials and high-quality data in this setting is notable and the optimal analgesic strategy for patients with moderately severe and severe AP still requires to be determined.
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Affiliation(s)
- Wenhao Cai
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China.,Liverpool Pancreatitis Research Group, Liverpool University Hospitals NHS Foundation Trust and Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Fei Liu
- Department of Anaesthesiology, Laboratory of Anaesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yongjian Wen
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Chenxia Han
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Manya Prasad
- Clinical Research and Epidemiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Qing Xia
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Robert Sutton
- Liverpool Pancreatitis Research Group, Liverpool University Hospitals NHS Foundation Trust and Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Wei Huang
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
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17
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Han C, Du D, Wen Y, Li J, Wang R, Jin T, Yang J, Shi N, Jiang K, Deng L, Fu X, Mukherjee R, Windsor JA, Hong J, Phillips AR, Sutton R, Huang W, Liu T, Xia Q. Chaiqin chengqi decoction ameliorates acute pancreatitis in mice via inhibition of neuron activation-mediated acinar cell SP/NK1R signaling pathways. JOURNAL OF ETHNOPHARMACOLOGY 2021; 274:114029. [PMID: 33731310 DOI: 10.1016/j.jep.2021.114029] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/17/2021] [Accepted: 03/10/2021] [Indexed: 02/06/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Chaiqin chengqi decoction (CQCQD) and its derivatives have been widely used in China for the early management of patients with acute pancreatitis (AP). Numerous studies demonstrate the anti-inflammatory and anti-oxidative effects of CQCQD and derivatives, but whether these effects can be attributed to suppressing neurogenic inflammation, has never been studied. AIM OF THE STUDY To investigate the effects of CQCQD on substance P (SP)-neurokinin 1 receptor (NK1R) based neurogenic inflammation in an experimental AP model. MATERIAL AND METHODS For AP patients on admission, pain score was accessed by visual analog scale (VAS); the levels of serum SP and expressions of pancreatic SP and NK1R were also determined. For in vivo study, mice received 7 intraperitoneal injections of cerulein (50 μg/kg) at hourly intervals to induce AP, whilst controls received normal saline injections. In the treatment groups, CQCQD (10 g/kg, 200 μl) was intragastrically given at the third, fifth, and seventh of the cerulein injection or the NK1R antagonist CP96345 (5 mg/kg) was intraperitoneally injected 30 min before the first cerulein administration. The von Frey test was performed to evaluate pain behavior. Animals were sacrificed at 12 h from the first cerulein/saline injection for severity assessment. Pharmacology network analysis was used to identify active ingredients of CQCQD for AP and pain. In vitro, freshly isolated pancreatic acinar cells were pre-treated with CQCQD (5 mg/ml), CP96345 (1 μM), or selected active compounds of CQCQD (12.5, 25, and 50 μM) for 30 min, followed by SP incubation for another 30 min. RESULTS The VAS score as well as the levels of serum SP and expressions of pancreatic SP-NK1R were up-regulated in moderately severe and severe patients compared with those with mild disease. CQCQD, but not CP96345, consistently and significantly ameliorated pain, pancreatic necrosis, and systemic inflammation in cerulein-induced AP as well as inhibited NK1R internalization of pancreatic acinar cells. These effects of CQCQD were associated with reduction of pancreatic SP-NK1R and neuron activity in pancreas, dorsal root ganglia, and spinal cord. Baicalin, emodin, and magnolol, the top 3 active components of CQCQD identified via pharmacology network analysis, suppressed NK1R internalization and NF-κB signal pathway activation in isolated pancreatic acinar cells. CONCLUSIONS CQCQD ameliorated cerulein-induced AP and its associated pain via inhibiting neuron activation-mediated pancreatic acinar cell SP-NK1R signaling pathways and its active compounds baicalin, emodin, and magnolol contributed to this effect.
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Affiliation(s)
- Chenxia Han
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Dan Du
- West China-Washington Mitochondria and Metabolism Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yongjian Wen
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jiawang Li
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Rui Wang
- Core Research Facilities, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Tao Jin
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jingyu Yang
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Na Shi
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Kun Jiang
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Lihui Deng
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xianghui Fu
- Division of Endocrinology and Metabolism, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, 610041, China
| | - Rajarshi Mukherjee
- Liverpool Pancreatitis Study Group, Royal Liverpool University Hospital and Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GE, United Kingdom
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1023, New Zealand
| | - Jiwon Hong
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1023, New Zealand; Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, 1010, New Zealand
| | - Anthony R Phillips
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1023, New Zealand; Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, 1010, New Zealand
| | - Robert Sutton
- Liverpool Pancreatitis Study Group, Royal Liverpool University Hospital and Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GE, United Kingdom
| | - Wei Huang
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Tingting Liu
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Qing Xia
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, 610041, China.
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18
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Doussot A, Decrock M, Calame P, Georges P, Turco C, Lakkis Z, Heyd B. Fluorescence-based pancreas stump perfusion is associated with postoperative acute pancreatitis after pancreatoduodenectomy a prospective cohort study. Pancreatology 2021; 21:S1424-3903(21)00161-7. [PMID: 34030965 DOI: 10.1016/j.pan.2021.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/30/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative acute pancreatitis (POAP) emerges as a distinct pancreas-specific complication increasing both the risk and the burden of POPF after pancreatoduodenectomy. Among various risk factors, pancreas stump (PS) hypoperfusion might play a role in POAP occurrence but has never been investigated. The current study aimed at evaluating the feasibility of intraoperative fluorescence angiography (IOFA) of the PS using ICG and its association with POAP. METHODS Consecutive patients who underwent pancreatoduodenectomy for a periampullary tumor with pancreatojejunostomy and PS perfusion assessment using IOFA between January 2020 and November 2020 were prospectively included. Perioperative management and surgical strategy were standardized. IOFA of the pancreas stump was performed before fashioning pancreatojejunostomy. POAP was defined according to the Connor definition and was confirmed upon radiological blind review. Outcomes between patients with normally perfused and hypoperfused PS were compared. POAP was the primary endpoint. RESULTS Among 30 patients, nine patients (30%) developed POAP according to the Connor definition, and six patients (20%) had CT-confirmed POAP. Upon IOFA, six patients (20%) presented PS hypoperfusion; of which one patient underwent extended pancreatectomy further to the left. PS hypoperfusion was statistically associated with the occurrence of POAP (80% vs. 16%; p = 0.011) and CT-confirmed POAP (60% vs. 12%; p = 0.041). Clinically relevant POPF rate was 40% in case of PS hypoperfusion and 4% in case of normal PS perfusion (p = 0.064). CONCLUSIONS PS perfusion assessment using IOFA seems safe and reliable to anticipate POAP. PS IOFA could be considered as a potential tool for perioperative assessment of surgical risk after pancreatoduodenectomy.
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Affiliation(s)
- Alexandre Doussot
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, France.
| | - Marc Decrock
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, France
| | - Paul Calame
- Department of Radiology, University Hospital of Besançon, France
| | - Pauline Georges
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, France
| | - Célia Turco
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, France
| | - Zaher Lakkis
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, France
| | - Bruno Heyd
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, France
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19
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Zheng Z, Ding YX, Qu YX, Cao F, Li F. A narrative review of the mechanism of acute pancreatitis and recent advances in its clinical management. Am J Transl Res 2021; 13:833-852. [PMID: 33841625 PMCID: PMC8014344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/15/2020] [Indexed: 06/12/2023]
Abstract
Acute pancreatitis (AP) is a common gastrointestinal disease with a high risk of mortality. Recently, the exosome and its potential regulatory role in the progression of AP has garnered the interest of researchers. However, effective drug interventions and therapeutic targets for AP remain to be established. Treatment approaches for AP have undergone considerable changes in the recent years: there is a greater preference for minimally invasive therapy (as primary treatment), multidisciplinary participation and the step-up approach. We aimed to discuss AP mechanism and the recent advancement in its treatment strategies to manage AP better in clinical practice.
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Affiliation(s)
- Zhi Zheng
- Department of General Surgery, Xuan Wu Hospital, Capital Medical UniversityBeijing 100053, China
- Clinical Center for Acute Pancreatitis, Capital Medical UniversityBeijing, China
| | - Yi-Xuan Ding
- Department of General Surgery, Xuan Wu Hospital, Capital Medical UniversityBeijing 100053, China
- Clinical Center for Acute Pancreatitis, Capital Medical UniversityBeijing, China
| | - Yuan-Xu Qu
- Department of General Surgery, Xuan Wu Hospital, Capital Medical UniversityBeijing 100053, China
- Clinical Center for Acute Pancreatitis, Capital Medical UniversityBeijing, China
| | - Feng Cao
- Department of General Surgery, Xuan Wu Hospital, Capital Medical UniversityBeijing 100053, China
- Clinical Center for Acute Pancreatitis, Capital Medical UniversityBeijing, China
| | - Fei Li
- Department of General Surgery, Xuan Wu Hospital, Capital Medical UniversityBeijing 100053, China
- Clinical Center for Acute Pancreatitis, Capital Medical UniversityBeijing, China
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Ede C, Ortiz R, Anderson LR. Effectiveness of thoracic epidural anesthesia in reducing morbidity and mortality in adults with acute pancreatitis: a systematic review protocol and meta-analysis. JBI Evid Synth 2020; 19:1237-1242. [PMID: 33230015 DOI: 10.11124/jbies-20-00119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review is to evaluate the effectiveness of thoracic epidural in reducing morbidity and mortality in adults with acute pancreatitis. INTRODUCTION Acute pancreatitis is a common disease that often results in significant morbidity and mortality. Although the use of a thoracic epidural anesthesia in patients with acute pancreatitis provides effective analgesia, there appears to be additional non-analgesic benefits associated with thoracic epidural anesthesia. INCLUSION CRITERIA Randomized controlled trials will be sought for inclusion, but this review will also consider quasi-experimental studies, cohort studies, case-controlled studies, cross-sectional studies, and case-series studies. Studies will include patients 18 years of age and older with acute pancreatitis, with no exclusion to comorbidity. Studies published in a language other than English will be excluded unless a translated version is available. METHODS The key databases to be searched include MEDLINE, CINAHL, OpenGrey, ClinicalTrials.gov, and Google Scholar. Studies will be assessed for inclusion by at least two independent reviewers. Included studies will be critically appraised by two independent reviewers using standardized critical appraisal instruments from JBI. Data will be extracted from studies included in the review using a standardized extraction tool. Studies will, where possible, be pooled in statistical meta-analysis using JBI SUMARI. SYSTEMATIC REVIEW REGISTRATION NUMBER The title of this protocol has been registered with the JBI Systematic Review Register. This manuscript has been registered with PROSPERO (CRD42020177756).
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Affiliation(s)
- Christa Ede
- Rosalind Franklin University of Medicine and Science: A JBI Affiliated Group, Chicago, IL, USA
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Affiliation(s)
| | - Karla Au Yeung
- Department of Pediatric Gastroenterology and Nutrition, and
| | - Brian Pugmire
- Department of Radiology, Valley Children's Hospital, Madera, CA
| | - Roberto Gugig
- Department of Pediatric Gastroenterology and Nutrition, and
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Boxhoorn L, Voermans RP, Bouwense SA, Bruno MJ, Verdonk RC, Boermeester MA, van Santvoort HC, Besselink MG. Acute pancreatitis. Lancet 2020; 396:726-734. [PMID: 32891214 DOI: 10.1016/s0140-6736(20)31310-6] [Citation(s) in RCA: 444] [Impact Index Per Article: 111.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 03/20/2020] [Accepted: 05/29/2020] [Indexed: 02/07/2023]
Abstract
Acute pancreatitis is an unpredictable and potentially lethal disease. The prognosis mainly depends on the development of organ failure and secondary infection of pancreatic or peripancreatic necrosis. In the past 10 years, treatment of acute pancreatitis has moved towards a multidisciplinary, tailored, and minimally invasive approach. Despite improvements in treatment and critical care, severe acute pancreatitis is still associated with high mortality rates. In this Seminar, we outline the latest evidence on diagnostic and therapeutic strategies for acute pancreatitis.
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Affiliation(s)
- Lotte Boxhoorn
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
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Mantuani D, Josh Luftig P, Herring A, Mian M, Nagdev A. Successful emergency pain control for acute pancreatitis with ultrasound guided erector spinae plane blocks. Am J Emerg Med 2020; 38:1298.e5-1298.e7. [DOI: 10.1016/j.ajem.2020.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 02/04/2020] [Accepted: 02/05/2020] [Indexed: 02/06/2023] Open
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Xu H, Li Y, Zhang J, Cheng L, Pan S. The study of automatic matching and optimal location of epidural anesthesia based on ultrasonic image processing. JOURNAL OF INTELLIGENT & FUZZY SYSTEMS 2020. [DOI: 10.3233/jifs-179608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Hui Xu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Department of Anesthesiology, The Third People’s Hospital of Bengbu, Bengbu, Anhui, China
| | - Yuanhai Li
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jingjun Zhang
- Department of Anesthesiology, The Third People’s Hospital of Bengbu, Bengbu, Anhui, China
| | - Liang Cheng
- Department of Anesthesiology, The Third People’s Hospital of Bengbu, Bengbu, Anhui, China
| | - Song Pan
- Department of Anesthesiology, The Third People’s Hospital of Bengbu, Bengbu, Anhui, China
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Tan JH, Zhou L, Kan HP, Zhang GW. Parecoxib Improves the Outcomes of Acute Mild and Moderate Pancreatitis: A 3-Year Matched Cohort Study Based on a Prospective Database. Pancreas 2019; 48:1148-1154. [PMID: 31593014 DOI: 10.1097/mpa.0000000000001393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the role of parecoxib in patients with different severities of acute pancreatitis (AP). METHODS A total of 772 eligible patients with AP were divided into 4 groups: mild and moderately AP (MAP) treated with parecoxib (group A, n = 236), MAP without parecoxib treatment (group B, n = 453), severe AP (SAP) treated with parecoxib (group C, n = 28), and SAP without parecoxib treatment (group D, n = 55). Patients in group A were exactly matched with patients in group B by propensity score matching, similar to the matching between group C and group D. RESULTS The morbidity of abdominal infection in group A was significantly lower as compared with that in group B (P < 0.050). The progression of MAP to SAP significantly decreased in group A than group B (P < 0.050). No significant differences were observed between group C and group D. The risk factors independently related to the progression of MAP included alcoholic/high-fat dietary (P = 0.028) and parecoxib administration (P = 0.011). CONCLUSIONS Early administration of parecoxib could reduce the morbidity of complications among patients with MAP. Parecoxib may prevent the progression of MAP to SAP and improve its outcomes.
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Affiliation(s)
- Jie-Hui Tan
- From the Department of Hepatobiliary Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Birgin E, Reeg A, Téoule P, Rahbari NN, Post S, Reissfelder C, Rückert F. Early postoperative pancreatitis following pancreaticoduodenectomy: what is clinically relevant postoperative pancreatitis? HPB (Oxford) 2019; 21:972-980. [PMID: 30591305 DOI: 10.1016/j.hpb.2018.11.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 11/12/2018] [Accepted: 11/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND/OBJECTIVES Postoperative pancreatitis (POP) has recently been shown to be the cause of pancreatic fistula (POPF) following pancreaticoduodenectomy (PD). The aim of the present study was to document the perioperative outcome associated with POP and determine potential risk factors for POP. METHODS Patients undergoing PD between 2009 and 2015 were identified from the prospective data base at a single center. The previous suggested definition of POP by Connor was used. Complications were graded according to the Clavien-Dindo classification and by the grading proposed for POP. Risk factors for POP were analyzed by univariate and multivariate analysis. RESULTS Of 190 patients, a total of 100 patients (53%) developed POP of whom 22 (12%) and 13 (7%) had grade B and grade C complications, respectively. Elevated serum CRP-levels on postoperative day (POD) 2 and elevated serum lipase on POD 1 were associated with onset of cr-POP. CONCLUSION The proposed definition of POP constitutes a valuable tool to assess a serious pancreatic-surgery associated complication. Routine serum CRP and serum lipase levels on the first two postoperative days enable sufficient discrimination of clinically relevant POP.
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Affiliation(s)
- Emrullah Birgin
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
| | - Alina Reeg
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Patrick Téoule
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Nuh N Rahbari
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stefan Post
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Felix Rückert
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Trikudanathan G, Wolbrink DRJ, van Santvoort HC, Mallery S, Freeman M, Besselink MG. Current Concepts in Severe Acute and Necrotizing Pancreatitis: An Evidence-Based Approach. Gastroenterology 2019; 156:1994-2007.e3. [PMID: 30776347 DOI: 10.1053/j.gastro.2019.01.269] [Citation(s) in RCA: 194] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/01/2019] [Accepted: 01/15/2019] [Indexed: 02/07/2023]
Abstract
The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota.
| | | | - Hjalmar C van Santvoort
- Department of Surgery, the University Medical Center Utrecht and the St. Antonius Hospital Nieuwegein, the Netherlands
| | - Shawn Mallery
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Martin Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
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Govil D, Shafi M. Thoracic Epidural Analgesia for Severe Acute Pancreatitis: Quo Vadis Intensivist? Indian J Crit Care Med 2019; 23:59-60. [PMID: 31086447 PMCID: PMC6487610 DOI: 10.5005/jp-journals-10071-23117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
How to cite this article: Govil D, Shafi M. Thoracic Epidural Analgesia for Severe Acute Pancreatitis: Quo Vadis Intensivist? Indian J of Crit Care Med 2019;23(2):59-60.
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Affiliation(s)
- Deepak Govil
- Institute of Anesthesia and Critical Care, Medanta The Medicity, Gurugram, Haryana, India
| | - Mozammil Shafi
- Institute of Anesthesia and Critical Care, Medanta The Medicity, Gurugram, Haryana, India
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Tyagi A, Gupta YR, Das S, Rai G, Gupta A. Effect of Segmental Thoracic Epidural Block on Pancreatitisinduced Organ Dysfunction: A Preliminary Study. Indian J Crit Care Med 2019; 23:89-94. [PMID: 31086453 PMCID: PMC6487603 DOI: 10.5005/jp-journals-10071-23123] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND This preliminary randomized controlled study evaluated effect of thoracic epidural block (TEB) on progression of acute pancreatitis induced organ dysfunction/failure. MATERIALS AND METHODS Patients with predicted severe acute pancreatitis, without contraindication to TEB were randomized to receive (group TE) or not receive a TEB (group NTE) (n = 16 each). For group TE, TEB was performed at T8-9 or T9-10 vertebral level, with infusion of ropivacaine (0.2%) along with fentanyl 2 µg/mL; in group NTE, intravenous morphine was used instead, both interventions titrated to NRS of <4. SOFA score was assessed daily till discharge from ICU, and aggregate SOFA calculated by summing worst scores for each of organ system during ICU stay as primary outcome measure. Other surrogate measures of patient outcome were recorded as secondary objectives. RESULTS Aggregate SOFA score was statistically similar between both groups (group NTE: 3 [2 - 4]; group TE: 5 [2 - 6]) (P = 0.379); but there was trend of improvement in SOFA score in group TE versus a worsening in group NTE. Duration of hospital stay, and number of patients requiring mechanical ventilation were statistically similar; mortality was insignificantly lesser for group TE (12.5% versus 6.6%; p = 1.000). Fall in serum procalcitonin was significantly greater for group TE. CONCLUSION Thoracic epidural was associated with insignificant clinical trend towards better organ functions and lesser mortality; along with significantly greater fall in serum procalcitonin. These are encouraging results that could guide future use of thoracic epidural in acute pancreatitis for its non-analgesic benefits. HOW TO CITE THIS ARTICLE Tyagi A, Gupta YR et al. Effect of Segmental Thoracic Epidural Block on Pancreatitis Induced Organ Dysfunction: A Preliminary Study. Indian J of Crit Care Med 2019;23(2):89-94.
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Affiliation(s)
- Asha Tyagi
- Department of Anesthesiology and Critical Care; University College of Medical Sciences and GTB Hospital, NCT of Delhi, India
| | - Yash Raj Gupta
- Department of Anesthesiology and Critical Care; University College of Medical Sciences and GTB Hospital, NCT of Delhi, India
| | - Shukla Das
- Department of Microbiology; University College of Medical Sciences and GTB Hospital, NCT of Delhi, India
| | - Gargi Rai
- Department of Microbiology; University College of Medical Sciences and GTB Hospital, NCT of Delhi, India
| | - Arun Gupta
- Department of Surgery; University College of Medical Sciences and GTB Hospital, NCT of Delhi, India
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Winsö O, Kral J, Wang W, Kralova I, Abrahamsson P, Johansson G, Blind PJ. Thoracic epidural anaesthesia reduces insulin resistance and inflammatory response in experimental acute pancreatitis. Ups J Med Sci 2018; 123:207-215. [PMID: 30468105 PMCID: PMC6327622 DOI: 10.1080/03009734.2018.1539054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
AIMS The activity of the sympathetic nervous system (SNS) is crucial at an early stage in the development of an inflammatory reaction. A study of metabolic events globally and locally in the early phase of acute pancreatitis (AP), implying hampered SNS activity, is lacking. We hypothesized that thoracic epidural anaesthesia (TEA) modulates the inflammatory response and alleviates the severity of AP in pigs. MATERIAL AND METHODS The taurocholate (TC) group (n = 8) had only TC AP. The TC + TEA group (n = 8) had AP and TEA. A control group (n = 8) underwent all the preparations, without having AP or TEA. Metabolic changes in the pancreas were evaluated by microdialysis and by histopathological examination. RESULTS The relative increase in serum lipase concentrations was more pronounced in the TC group than in TC + TEA and control groups. A decrease in relative tissue oxygen tension (PtiO2) levels occurred one hour later in the TC + TEA group than in the TC group. The maintenance of normoglycaemia in the TC group required a higher glucose infusion rate than in the TC + TEA group. The relative decrease in serum insulin concentrations was most pronounced in the TC + TEA group. CONCLUSION TEA attenuates the development of AP, as indicated by changes observed in haemodynamic parameters and by the easier maintenance of glucose homeostasis. Further, TEA was associated with attenuated insulin resistance and fewer local pathophysiological events.
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Affiliation(s)
- Ola Winsö
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
- CONTACT Professor Ola Winsö, MD, PhD Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, SE-901 85Umeå, Sweden
| | - Josef Kral
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Wanzhong Wang
- Department of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden
| | - Ivana Kralova
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Pernilla Abrahamsson
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Göran Johansson
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Per-Jonas Blind
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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The authors reply. Crit Care Med 2018; 46:e721-e722. [DOI: 10.1097/ccm.0000000000003111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Nearly all patients with acute pancreatitis (AP) experience some degree of abdominal pain that is severe enough to prompt medical evaluation and necessitate analgesia. Effective analgesia is a priority in caring for such patients. Despite its importance, strategies for pain management in AP have been poorly studied, particularly in the field of pediatrics. Presently, no published data examine the management of pain because of AP in children at the time of initial presentation. Management approaches are often extrapolated from adult practice and based on anecdotal experience in the absence of objective data. The aim of our study was to examine the initial provision of analgesia to children who presented to a pediatric emergency department with AP.
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Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr 2018; 66:159-176. [PMID: 29280782 PMCID: PMC5755713 DOI: 10.1097/mpg.0000000000001715] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the incidence of acute pancreatitis (AP) in children is increasing, management recommendations rely on adult published guidelines. Pediatric-specific recommendations are needed. METHODS The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas committee performed a MEDLINE review using several preselected key terms relating to management considerations in adult and pediatric AP. The literature was summarized, quality of evidence reviewed, and statements of recommendations developed. The authorship met to discuss the evidence, statements, and voted on recommendations. A consensus of at least 75% was required to approve a recommendation. RESULTS The diagnosis of pediatric AP should follow the published INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE definitions (by meeting at least 2 out of 3 criteria: (1) abdominal pain compatible with AP, (2) serum amylase and/or lipase values ≥3 times upper limits of normal, (3) imaging findings consistent with AP). Adequate fluid resuscitation with crystalloid appears key especially within the first 24 hours. Analgesia may include opioid medications when opioid-sparing measures are inadequate. Pulmonary, cardiovascular, and renal status should be closely monitored particularly within the first 48 hours. Enteral nutrition should be started as early as tolerated, whether through oral, gastric, or jejunal route. Little evidence supports the use of prophylactic antibiotics, antioxidants, probiotics, and protease inhibitors. Esophago-gastro-duodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography have limited roles in diagnosis and management. Children should be carefully followed for development of early or late complications and recurrent attacks of AP. CONCLUSIONS This clinical report represents the first English-language recommendations for the management of pediatric AP. Future aims should include prospective multicenter pediatric studies to further validate these recommendations and optimize care for children with AP.
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Early management of acute pancreatitis: A review of the best evidence. Dig Liver Dis 2017; 49:585-594. [PMID: 28262458 DOI: 10.1016/j.dld.2017.01.168] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/27/2017] [Accepted: 01/27/2017] [Indexed: 12/11/2022]
Abstract
In the 20th century early management of acute pancreatitis often included surgical intervention, despite overwhelming mortality. The emergence of high-quality evidence (randomized controlled trials and meta-analyses) over the past two decades has notably shifted the treatment paradigm towards predominantly non-surgical management early in the course of acute pancreatitis. The present evidence-based review focuses on contemporary aspects of early management (which include analgesia, fluid resuscitation, antibiotics, nutrition, and endoscopic retrograde cholangiopancreatography) with a view to providing clear and succinct guidelines on early management of patients with acute pancreatitis in 2017 and beyond.
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Bulyez S, Pereira B, Caumon E, Imhoff E, Roszyk L, Bernard L, Bühler L, Heidegger C, Jaber S, Lefrant JY, Chabanne R, Bertrand PM, Laterre PF, Guerci P, Danin PE, Escudier E, Sossou A, Morand D, Sapin V, Constantin JM, Jabaudon M. Epidural analgesia in critically ill patients with acute pancreatitis: the multicentre randomised controlled EPIPAN study protocol. BMJ Open 2017; 7:e015280. [PMID: 28554928 PMCID: PMC5730003 DOI: 10.1136/bmjopen-2016-015280] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Acute pancreatitis (AP) is associated with high morbidity and mortality in its most severe forms. Most patients with severe AP require intubation and invasive mechanical ventilation, frequently for more than 7 days, which is associated with the worst outcome. Recent increasing evidence from preclinical and clinical studies support the beneficial effects of epidural analgesia (EA) in AP, such as increased gut barrier function and splanchnic, pancreatic and renal perfusion, decreased liver damage and inflammatory response, and reduced mortality. Because recent studies suggest that EA might be a safe procedure in the critically ill, we sought to determine whether EA reduced AP-associated respiratory failure and other major clinical outcomes in patients with AP. METHODS AND ANALYSIS The Epidural Analgesia for Pancreatitis (EPIPAN) trial is an investigator-initiated, prospective, multicentre, randomised controlled two-arm trial with assessor-blinded outcome assessment. The EPIPAN trial will randomise 148 patients with AP requiring admission to an intensive care unit (ICU) to receive EA (with patient-controlled epidural administration of ropivacaine and sufentanil) combined with standard care based on current recommendations on the treatment of AP (interventional group), or standard care alone (reference group). The primary outcome is the number of ventilator-free days at day 30. Secondary outcomes include main complications of AP (eg, organ failure and mortality, among others), levels of biological markers of systemic inflammation, epithelial lung injury, renal failure, and healthcare-associated costs. ETHICS AND DISSEMINATION The study was approved by the appropriate ethics committee (CPP Sud-Est VI). Informed consent is required. If the combined application of EA and standard care proves superior to standard care alone in patients with AP in the ICU, the use of EA may become standard practice in experienced centres, thereby decreasing potential complications related to AP and its burden in critically ill patients. The results will be disseminated in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02126332.
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Affiliation(s)
- Stéphanie Bulyez
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Elodie Caumon
- Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Etienne Imhoff
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Laurence Roszyk
- Department of Medical Biochemistry and Molecular Biology, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Lise Bernard
- Department of Pharmacy, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, Clermont-Ferrand, France
| | - Leo Bühler
- Department of Surgery, Geneva university hospitals, Geneva, Switzerland
| | - Claudia Heidegger
- Division of Intensive Care, Geneva university hospitals, Geneva, Switzerland
| | - Samir Jaber
- Department of Anesthesiology and Critical Care Medicine B (DAR B), Saint-Eloi teaching hospital, Montpellier university hospital, Montpellier, France
| | - Jean-Yves Lefrant
- Division of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes university hospital and EA 2992, Université Montpellier, Nîmes, France
| | - Russell Chabanne
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Pierre-François Laterre
- Department of Critical Care Medicine, Saint Luc university hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Philippe Guerci
- Department of Anesthesiology and Intensive Care Medicine, Nancy university hospital, Nancy, France
| | - Pierre-Eric Danin
- Anesthesia and Surgical Intensive Care, Nice Archet 2 university hospital and INSERM U1065, team 8, Nice, France
| | - Etienne Escudier
- Intensive Care Unit, Annecy Genevois general hospital, Annecy, France
| | - Achille Sossou
- Department of Anesthesiology and Critical Care Medicine, Emile-Roux general hospital, Le Puy-en-Velay, France
| | - Dominique Morand
- Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Vincent Sapin
- Department of Medical Biochemistry and Molecular Biology, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
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Connor S. Defining post-operative pancreatitis as a new pancreatic specific complication following pancreatic resection. HPB (Oxford) 2016; 18:642-51. [PMID: 27485058 PMCID: PMC4972444 DOI: 10.1016/j.hpb.2016.05.006] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/08/2016] [Accepted: 05/17/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Post-operative pancreatic fistula has been well defined. However the underlying aetiology remains poorly understood. The aim of this review was to investigate whether the underlying aetiology for a proportion of patients suffering from post-operative pancreatic fistula was due to post-operative pancreatitis. METHOD A systematic literature review according to the PRISMA guidelines. The date range was from 2005 to 2016. The search strategy included the terms: post-operative pancreatitis, pathophysiology, post-operative pancreatic fistula, pancreaticoduodenectomy, ischaemic pancreatitis, microcirculation and pancreatitis, serum and drain amylase and lipase. The data was summarised without quantitative or qualitative analysis. RESULTS There exists significant physiological, biochemical, clinical and histological evidence in the literature that a proportion of post-operative pancreatic fistula is due to post-operative pancreatitis. A new definition of post-operative pancreatitis based on the presence of biochemical evidence for pancreatic inflammation (urinary trypsinogen-2 >50 ug/L or serum amylase/lipase > upper limit of normal) between post-operative days 0-2. Predicted severity is based on C-reactive protein with a cut-off of 180 mg/L at post-operative day 2. The proposed grading of severity is in line with previous work by international study group of pancreatic surgery. CONCLUSION Post-operative pancreatitis should be recognised as a separate pancreatic specific complication following pancreatic resection. Improved recognition may allow better understanding of potential methods of prevention, treatment and prediction of severity.
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Affiliation(s)
- Saxon Connor
- Correspondence Saxon Connor, Department of Surgery, Christchurch Hospital, Christchurch, New Zealand. Tel: +64 3 3640640. Fax: +64 3 3640352.Department of SurgeryChristchurch HospitalChristchurchNew Zealand
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Windisch O, Heidegger CP, Giraud R, Morel P, Bühler L. Thoracic epidural analgesia: a new approach for the treatment of acute pancreatitis? Crit Care 2016; 20:116. [PMID: 27141977 PMCID: PMC4855315 DOI: 10.1186/s13054-016-1292-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This review article analyzes, through a nonsystematic approach, the pathophysiology of acute pancreatitis (AP) with a focus on the effects of thoracic epidural analgesia (TEA) on the disease. The benefit-risk balance is also discussed. AP has an overall mortality of 1 %, increasing to 30 % in its severe form. The systemic inflammation induces a strong activation of the sympathetic system, with a decrease in the blood flow supply to the gastrointestinal system that can lead to the development of pancreatic necrosis. The current treatment for severe AP is symptomatic and tries to correct the systemic inflammatory response syndrome or the multiorgan dysfunction. Besides the removal of gallstones in biliary pancreatitis, no satisfactory causal treatment exists. TEA is widely used, mainly for its analgesic effect. TEA also induces a targeted sympathectomy in the anesthetized region, which results in splanchnic vasodilatation and an improvement in local microcirculation. Increasing evidence shows benefits of TEA in animal AP: improved splanchnic and pancreatic perfusion, improved pancreatic microcirculation, reduced liver damage, and significantly reduced mortality. Until now, only few clinical studies have been performed on the use of TEA during AP with few available data regarding the effect of TEA on the splanchnic perfusion. Increasing evidence suggests that TEA is a safe procedure and could appear as a new treatment approach for human AP, based on the significant benefits observed in animal studies and safety of use for human. Further clinical studies are required to confirm the clinical benefits observed in animal studies.
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Affiliation(s)
- Olivier Windisch
- />Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | | | - Raphaël Giraud
- />Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Philippe Morel
- />Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Léo Bühler
- />Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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