Hydroxyethyl starch resuscitation downregulate pro-inflammatory cytokines in the early phase of severe acute pancreatitis: A retrospective study

Controversies in the management of acute pancreatitis: An update

This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.

Fire in the belly: A scoping review of the immunopathological mechanisms of acute pancreatitis

Introduction

Acute pancreatitis (AP) is characterised by an inflammatory response that in its most severe form can cause a systemic dysregulated immune response and progression to acute multi-organ dysfunction. The pathobiology of the disease is unclear and as a result no targeted, disease-modifying therapies exist. We performed a scoping review of data pertaining to the human immunology of AP to summarise the current field and to identify future research opportunities.

Methods

A scoping review of all clinical studies of AP immunology was performed across multiple databases. Studies were included if they were human studies of AP with an immunological outcome or intervention.

Results

205 studies met the inclusion criteria for the review. Severe AP is characterised by significant immune dysregulation compared to the milder form of the disease. Broadly, this immune dysfunction was categorised into: innate immune responses (including profound release of damage-associated molecular patterns and heightened activity of pattern recognition receptors), cytokine profile dysregulation (particularly IL-1, 6, 10 and TNF-α), lymphocyte abnormalities, paradoxical immunosuppression (including HLA-DR suppression and increased co-inhibitory molecule expression), and failure of the intestinal barrier function. Studies including interventions were also included. Several limitations in the existing literature have been identified; consolidation and consistency across studies is required if progress is to be made in our understanding of this disease.

Conclusions

AP, particularly the more severe spectrum of the disease, is characterised by a multifaceted immune response that drives tissue injury and contributes to the associated morbidity and mortality. Significant work is required to develop our understanding of the immunopathology of this disease if disease-modifying therapies are to be established.

Characteristics of New Oxygen-Carrying Plasma and Its Application Prospects in the Treatment of Severe Acute Pancreatitis

ABSTRACT

Oxygen-carrying plasma, a new type of colloid substitute, is composed of hydroxyethyl starch and acellular hemoglobin-based oxygen carriers. It can supplement colloidal osmotic pressure and rapidly improve the body's oxygen supply. The resuscitation effect of the new oxygen-carrying plasma in animal shock models is better than that of hydroxyethyl starch or hemoglobin-based oxygen carriers alone. It can reduce the histopathological damage and mortality associated with severe acute pancreatitis, and it is expected to become an interesting treatment method for severe acute pancreatitis. This article reviews the characteristics of the new oxygen-carrying plasma, its role in fluid resuscitation, and its application prospects in the treatment of severe acute pancreatitis.

Early fluid resuscitation in severe acute pancreatitis

Acute pancreatitis (AP) is a common clinical emergency disorder, and its morbidity is increasing gradually. Severe AP (SAP) often occurs with a sudden onset and high mortality. Microcirculation disturbance and hemodynamic abnormality is one of the main pathophysiologic mechanisms of SAP. Early fluid resuscitation is the cornerstone of therapy. However, at present, the fluid type, the amount of fluid resuscitation, and the rehydration rate are still in dispute. Early goal-directed fluid therapy as an important individualized liquid resuscitation strategy has great significance to improve the prognosis of SAP. This article reviews the pathophysiological mechanisms of microcirculation disturbance, the related dispute of liquid resuscitation therapy, and the application of early goal-directed treatment strategy.

Clinical significance of serum total oxidant/antioxidant status in patients with operable and advanced gastric cancer

Purpose

Oxidative stress was significantly associated with the development of malignancies. The purpose of this study was to evaluate the significance of serum total oxidant/antioxidant status in operable advanced gastric cancer patients.

Materials and methods

A total of 284 patients who underwent curative resection for primary stage III gastric cancer were enrolled. Total oxidant status, total antioxidant status, and oxidative stress index (OSI) were evaluated within 24 hours before surgery, and compared with 120 healthy donors. The correlation between the OSI and survival outcome was analyzed by the Kaplan–Meier method with log-rank test and Cox’s regression methods, respectively.

Results

Mean OSI of gastric cancer patients was higher than healthy controls (1.41±0.96 vs 0.78±0.42, P<0.001). All patients were stratified into two groups using the optimal cutoff value (1.42) of OSI using a sensitivity of 94.1% and a specificity of 64.0% as optimal conditions from receiver operating curve analysis. Patients with an OSI ≥1.42 had poorer mean overall survival (45.6 vs 29.8 months, P=0.022) and mean recurrence-free survival (43.3 vs 28.1 months, P=0.011) than patients with an OSI <1.42 in univariate analysis, and OSI was also confirmed as an independent predictor for survival for gastric cancer in multivariate analysis (hazard ratio, 0.541; 95% CI: 0.127–1.102; P=0.01).

Conclusion

Preoperative OSI can be considered as an independent prognostic factor for operable and advanced gastric cancer.

Significance of preoperative ischemia- modified albumin in operable and advanced gastric cancer

BACKGROUND

Oxidative stress plays an important role in promoting proliferation and metastases of cancer, which can be represented by ischemia-modified albumin (IMA). The purpose of this study was to evaluate serum IMA level in patients with operable advanced gastric cancer and analyze its prognostic significance.

MATERIALS AND METHODS

A total of 274 patients with primary stage III gastric cancer underwent curative operation were enrolled in this study. Serum IMA level was measured within 24 hours before surgery, comparing with 112 healthy donors. The correlation between serum IMA level and survival outcome was analyzed by the Kaplan-Meier with Log-Rank test and Cox's regression methods, respectively.

RESULTS

Serum IMA level from gastric cancer was higher than healthy control (0.41 ± 0.12 VS 0.23 ± 0.08; P< 0.001). Finally, 173 and 181 patients out of all 274 patients studied had died and recurrent, respectively. All patients were stratified into two groups using the optimal cutoff value (0.45) of IMA level using a sensitivity of 92.5% and a specificity of 65.2% as optimal conditions from receiver operating curve analysis. Patients with a IMA ⩾ 0.45 had poorer mean overall survival (44.68 months VS 30.94 months, P= 0.010) and mean recurrence free survival (42.36 months VS 28.82 months, p= 0.01) than patients with a IMA < 0.45 in univariate analysis and IMA also been confirmed as independent predictor for survival for GC patients in multivariate analysis (OR, 0.731; 95% CI: 0.329-1.282; p= 0.023).

CONCLUSIONS

Serum IMA level can be considered as an independent prognostic factor for operable and advanced gastric cancer.

Prognostic significance of ischemia-modified albumin for severe acute pancreatitis

Background: Severe acute pancreatitis (SAP) is characterized by the noxious combination of severe systemic inflammation and hypoperfusion and oxidative stress. Ischemia-modified albumin (IMA) was recognized as a novel marker of oxidative stress and ischemia. The purpose of this study was to evaluate serum IMA level in patients with SAP and analyze its prognostic significance. Methods: A total of 72 patients with SAP were enrolled. Serum IMA level was measured within 24 hours of the onset of SAP, and baseline characteristics were recorded. The BISAP, APACHE II and SOFA scores were calculated. Multivariate logistic regression and receiver operating characteristic curve analyses were used to evaluate predictive ability of LMA for in-hospital mortality of SAP. Kaplan-Meier analysis was further used to compare in-hospital mortality difference between high LMA and low LMA. Results: The overall in-hospital mortality rate of all 72 SAP patients was 23.6%. Non-survivor group had higher serum IMA (107.2±10.8 VS 88.4±11.9, P<0.05) than survivor group. Otherwise, the optimal cutoff levels for the IMA predicting in-hospital mortality of patients with SAP was 112 U/ml using a sensitivity of 77.4% and a specificity of 76.2% as optimal conditions (AUC, 0.734; 95% CI: 0.615-0.852; P=0.002). IMA level also was confirmed as an independent prognostic factor for SAP in multivariate analysis. Patient with high IMA level (≥112 U/ml) had poorer survival rate than low IMA (<112 U/ml) in log-rank test of Kaplan-Meier survival analysis (P<0.05). Conclusions: Serum IMA level can be considered as an independent predictor for in-hospital mortality of patients with SAP.