Revised Clinical Practice Guidelines of the Korean Pancreatobiliary Association for Acute Pancreatitis

Digital single-operator cholangioscopy for difficult anastomotic biliary strictures in living donor liver transplant recipients after failure of standard ERCP: SPYPASS-2 study (with videos)

BACKGROUND AND AIMS

Liver transplantation (LT) is a curative treatment for end-stage liver disease. Anastomotic biliary strictures (ABSs) are more common in living donor LT (LDLT). However, the success rate of ERCP for ABS remains unsatisfactory. In this study, we evaluated the efficacy of single-operator cholangioscopy (SOC) for ABS treatment in LDLT recipients where standard ERCP failed to access the stricture.

METHODS

This prospective study included 40 LDLT patients undergoing ERCP with SOC (SpyGlass DS II; Boston Scientific Corp, Natick, Mass, USA) to treat ABSs when guidewire placement across the ABS was difficult during conventional ERCP (cannulation time >10 minutes) between October 2021 and May 2023. Our primary endpoint was technical success, defined as successful guidewire placement across the ABS and/or subsequent treatment. Secondary endpoints were rates of clinical success, adverse events, and reintervention.

RESULTS

The mean patient age was 59.7 ± 7.2 years, and the mean time from LDLT to the occurrence of ABS was 212 ± 230 days. Technical and clinical success were achieved in 92.5% (37/40) and 82.5% (33/40) of patients, respectively. The rates of post-ERCP cholangitis, pancreatitis, and bleeding were 10.0%, 15.0%, and 2.5%, respectively. Intestinal perforation did not occur, and all adverse events were mild in severity. Early stent migration within 1 month occurred in 2 patients (5.4%), and 4 patients (10.8%) required reintervention within 1 month.

CONCLUSIONS

This study shows the efficacy and safety of SOC-facilitated management for difficult ABSs in LDLT patients after failure of standard ERCP. (Clinical trial registration number: NCT05065125.).

Case Study on Analysing the Early Disease Detection of Pancreatic Ductal Adenocarcinoma in Korean Association for Clinical Oncology

OBJECTIVES

Pancreatic ductal adenocarcinoma (PDAC) is the most pervasive sort of pancreatic malignant growth. Due to the lack of early symptoms and effective methods for early detection and screening, the majority of patients (80% to 85%) are diagnosed with advanced metastatic or locally advanced disease, resulting in a low 5-year survival rate of 12%. The case study represents a comprehensive investigation into the intricate landscape of pancreatic cancer diagnosis within the Korean population.

METHODS

Grounded in epidemiological bits of knowledge, the review plans to disentangle the particular examples, commonness, and segment attributes of PDAC in Korea. By scrutinizing current diagnostic modalities, including conventional imaging techniques, molecular markers, and emerging technologies, the research seeks to evaluate the strengths and limitations of existing approaches within the Korean clinical context. Central to the study is an exploration of the collaborative initiatives spearheaded by the Association of Clinical Oncology in Korea in the domain of PDAC early detection. Analysing research projects, clinical trials, and interdisciplinary collaborations, the case study sheds light on the association's pivotal role in driving innovation and progress in oncology.

RESULTS

The goal is to offer a detailed analysis of how the association helps in furthering knowledge and enhancing results in the management of PDAC. The case study delves into the implications of early PDAC detection for patient outcomes, emphasizing the significance of timely interventions and tailored treatment strategies. By outlining the potential benefits and challenges associated with early diagnosis, the study aims to inform health care policies, shape clinical guidelines, and guide future research priorities.

CONCLUSION

Through a holistic approach, the case study endeavours to offer important experiences into the multifaceted landscape of PDAC early detection within the Korean health care system, contributing to the broader discourse on effective oncological practices and patient care.

Evaluating the prognostic performance of the novel ERAP score in Vietnamese acute pancreatitis patients

Early recognition of severe acute pancreatitis (AP) is crucial for timely intervention. This study aims to evaluate the prognostic accuracy of the Emergency Room Assessment of AP (ERAP) score and compare it with the Bedside Index for Severity in AP (BISAP) score in predicting severe AP, mortality, and persistent multiple organ failure (MOF) in Vietnamese patients. This prospective cohort study included AP patients admitted to Cho Ray Hospital between August 2021 and May 2022. Patient data, including demographics, clinical presentations, and laboratory results, were collected upon admission. The ERAP and BISAP scores were calculated from these admission data. The prognostic accuracy for severe AP, mortality, and persistent MOF was assessed via the area under the receiver-operating characteristic curve (AUC). Among 167 AP patients (mean age 41.5 ± 12.0 years), hypertriglyceridemia (34.7%) and alcohol (22.2%) were the most prevalent etiologies. Severe AP accounted for 33.5% of the patients. Mortality rates were higher in persistent MOF patients (42.9%) than in persistent single-organ failure patients (3.6%), with a P value <.001. The ERAP score had AUCs for predicting severe AP, mortality, and persistent MOF of 0.899, 0.817, and 0.867, respectively, with an optimal cutoff of ≥2. The ERAP score had a better prognostic value than the BISAP score in predicting severe AP (AUC: 0.899 vs 0.820; P = .0072) and persistent MOF (AUC: 0.867 vs 0.785; P = .0193) but had a similar prognostic value for mortality (AUC: 0.817 vs 0.728; P = .0628). The ERAP score has strong predictive value for severe AP and persistent MOF, surpassing the BISAP score in these categories while maintaining similar accuracy for mortality prediction in the Vietnamese population. The ERAP score can be a valuable tool for the early identification of high-risk AP patients, enabling timely and appropriate clinical interventions.

Current Diagnosis and Treatment of Acute Pancreatitis in Korea: A Nationwide Survey

Background/Aims

Acute pancreatitis (AP) is a leading cause of emergency hospitalization. We present the current diagnostic and therapeutic status of AP as revealed by analysis of a large multicenter dataset.

Methods

The medical records of patients diagnosed with AP between 2018 and 2019 in 12 tertiary medical centers in Korea were retrospectively reviewed.

Results

In total, 676 patients were included, of whom 388 (57.4%) were male, and the mean age of all patients was 58.6 years. There were 355 (52.5%), 301 (44.5%), and 20 (3.0%) patients with mild, moderate, and severe AP, respectively, as assessed by the revised Atlanta classification. The most common etiologies of AP were biliary issues (41.6%) and alcohol consumption (24.6%), followed by hypertriglyceridemia (6.8%). The etiology was not identified in 111 (16.4%) patients at the time of initial admission. The overall mortality rate was 3.3%, increasing up to 45.0% among patients with severe AP. Notably, 70.0% (14/20) of patients with severe AP and 81.5% (154/189) of patients with systemic inflammatory response syndrome had received <4 L per day during the initial 24 hours of admission. Only 23.8% (67/281) of acute biliary pancreatitis patients underwent cholecystectomy during their initial admission. In total, 17.8% of patients experienced recurrent attacks during follow-up. However, none of the patients with acute biliary pancreatitis experienced recurrent attacks if they had undergone cholecystectomy during their initial admission.

Conclusions

This study provides insights into the current status of AP in Korea, including its etiology, severity, and management. Results reveal disparities between clinical guidelines and their practical implementation for AP treatment.

Heart rate variability in acute pancreatitis: a narrative review

Background and Objective

Acute pancreatitis (AP) is a complex inflammatory disorder with potential systemic repercussions including sepsis, multiple organ failure and mortality. As such, the development of a prognostic tool to assess the complications and severity of AP is critical as urgent medical intervention is warranted in cases of severe AP to prevent complications and reduce mortality. Despite the plethora of scoring systems such as the Acute Physiology and Chronic Health Evaluation II (APACHE II) score available for prognostication of AP, they often require manual invasive blood testing and lack the ability to monitor the dynamic progression of the disease. To this end, heart rate variability (HRV), a measure of the autonomic nervous system's modulation on cardiac activity, has emerged as a promising tool. Having been previously posited as a tool to monitor the progression of cardiovascular and neurological conditions, the use of HRV as a risk stratification tool for AP is highly plausible. Therefore, this study aims to synthesize the existing literature regarding the usage of HRV as a tool for the prognostication and monitoring of AP.

Methods

A comprehensive literature search was conducted in PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus and Embase from inception to December 2023. Articles with mentions of AP and HRV were reviewed, and the complications of AP and its effects on HRV parameters were analyzed.

Key Content and Findings

Early studies on the use of HRV in AP have revealed the association of decreased HRV parameters with the development of subsequent complications, reflecting the suppression of sympathetic activity as a predominant driving force. In addition, HRV has also been shown to outperform other established scoring systems in predicting outcomes of the complications of AP, but more studies are needed to validate its accuracy.

Conclusions

Preliminary studies have shown that certain parameters of HRV may be used to predict the severity of AP and prognosticate outcomes. Although HRV monitoring demonstrates potential to be superior to existing scoring systems in AP, more research is needed to validate its use as a prognostic tool. Nevertheless, the prospective utility of HRV monitoring in predicting the onset and outcomes of AP and its complications remains optimistic.

The Ongoing Debate on the Use of Prophylactic Antibiotics in Acute Pancreatitis-Is There a Conclusion? A Comprehensive Narrative Review

Acute pancreatitis (AP) is a common but often self-limiting disease in the majority of patients. However, in the minority, who may progress to moderately severe or severe AP, high mortality risk has been reported. Infected pancreatitis necrosis (IPN) in necrotising pancreatitis has been shown to result in more than twice the mortality rate compared with in sterile pancreatic necrosis. This raises the question on whether prophylactic antibiotics (PABs) should be given in subgroups of AP to prevent superimposed infection to improve survival outcomes. Despite numerous randomised controlled trials (RCTs), meta-analyses, and guidelines on the management of AP, there is a lack of strong evidence to suggest the use of PABs in AP. Additionally, use of PABs is associated with antimicrobial resistance. Considerable heterogeneity exists and limits the interpretation of results-subgroup of AP benefitting from PAB use, choice/class of PAB, and timing of administration from symptom onset and duration of PAB use. Only a minority of existing meta-analyses suggest mortality benefits and reduction in IPN. The majority of existing guidelines do not recommend the use of PABs in AP. More research is required to make more definitive conclusions. Currently, PAB should only be administered after multidisciplinary discussions led by pancreatology experts.

Recent Treatment Strategies for Acute Pancreatitis

Acute pancreatitis (AP) is a leading gastrointestinal disease that causes hospitalization. Initial management in the first 72 h after the diagnosis of AP is pivotal, which can influence the clinical outcomes of the disease. Initial management, including assessment of disease severity, fluid resuscitation, pain control, nutritional support, antibiotic use, and endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis, plays a fundamental role in AP treatment. Recent updates for fluid resuscitation, including treatment goals, the type, rate, volume, and duration, have triggered a paradigm shift from aggressive hydration with normal saline to goal-directed and non-aggressive hydration with lactated Ringer's solution. Evidence of the clinical benefit of early enteral feeding is becoming definitive. The routine use of prophylactic antibiotics is generally limited, and the procalcitonin-based algorithm of antibiotic use has recently been investigated to distinguish between inflammation and infection in patients with AP. Although urgent ERCP (within 24 h) should be performed for patients with gallstone pancreatitis and cholangitis, urgent ERCP is not indicated in patients without cholangitis. The management approach for patients with local complications of AP, particularly those with infected necrotizing pancreatitis, is discussed in detail, including indications, timing, anatomical considerations, and selection of intervention methods. Furthermore, convalescent treatment, including cholecystectomy in gallstone pancreatitis, lipid-lowering medications in hypertriglyceridemia-induced AP, and alcohol intervention in alcoholic pancreatitis, is also important for improving the prognosis and preventing recurrence in patients with AP. This review focuses on recent updates on the initial and convalescent management strategies for AP.

A new in-hospital mortality prediction nomogram for intensive care unit patients with acute pancreatitis

Introduction

Acute pancreatitis (AP) is a prevalent inflammatory disease that can lead to severe abdominal pain and multiple organ failure, potentially resulting in pancreatic necrosis and persistent dysfunction. A nomogram prediction model was developed to accurately evaluate the prognosis and provide therapy guidance to AP patients.

Material and methods

Retrospective data extraction was performed using MIMIC-IV, an open-source clinical database, to obtain 1344 AP patient records, of which the primary dataset included 1030 patients after the removal of repeated hospitalizations. The prediction of in-hospital mortality (IHM) used the least absolute shrinkage and selection operator (LASSO) regression model to optimize feature selection. A multivariate logistic regression analysis was used to build a prediction model incorporating the selected features, and the C-index, calibration plot, and decision curve analysis (DCA) were utilized to evaluate the discrimination, calibration, and clinical applicability of the prediction model.

Results

The nomogram utilized a combination of indicators, including the SAPS II score, RDW, MBP, RR, PTT, and fluid-electrolyte disorders. Impressively, the model exhibited a satisfactory diagnostic performance, with area under the curve values of 0.892 and 0.856 for the training cohort and internal validation, respectively. Moreover, the calibration plots and the Hosmer-Lemeshow goodness-of-fit (HL) test revealed a strong correlation between the predicted and actual outcomes (p = 0.73), further confirming the reliability of our model. Notably, the results of the decision curve analysis (DCA) highlighted the superiority of our model over previously described scoring methods in terms of net clinical benefit, solidifying its value in clinical applications.

Conclusions

Our novel nomogram is a simple tool for accurately predicting IHM in ICU patients with AP. Treatment methods that enhance the factors involved in the model may contribute to increased in-hospital survival for these ICU patients.

Efficacy and safety of early enteral and intravenous fluid resuscitation in severe acute pancreatitis: a systematic review and meta-analysis

OBJECTIVE

To compare the efficacy and safety of enteral fluid resuscitation (via nasointestinal tube or colorectal tube) and intravenous fluid resuscitation (via intravenous route) in the early treatment of severe acute pancreatitis.

METHODS

In this study, 8 electronic databases (PubMed, Web of Science, Embase, Cochrane Library, Scopus, China HowNet database, Wanfang database, and VIP database) were searched to collect clinical studies from inception to June 12, 2022. After the quality evaluation and data extraction of the included studies, the RevMan 5.3 software was used for analysis.

RESULTS

A total of seven studies including 580 patients were studied in this meta-analysis, in which 291 cases were treated with enteral fluid resuscitation and 289 cases were treated with intravenous fluid resuscitation. Compared with the intravenous route group, the enteral route resuscitation group reduced the incidence of new organ failure (OR = 0.23, 95% CI: 0.12-0.43, P < 0.00001), the incidence of persistent organ failure (OR = 0.38, 95% CI: 0.22-0.64, P = 0.0003), the incidence of mechanical ventilation (OR = 0.15, 95% CI: 0.03-0.69, P = 0.01), the incidence of ICU care (OR = 0.49, 95% CI: 0.27-0.88, P = 0.02), and the incidence of pancreatic infection (OR = 0.38, 95% CI: 0.17-0.83, P = 0.02). There were no statistically significant differences in mortality (OR = 0.77, 95% CI: 0.35-1.66, P = 0.50), surgical intervention rate (OR = 0.47, 95% CI: 0.19-1.18, P = 0.11), and incidence of localized ascites (OR = 0.65, 95% CI: 0.25-1.73, P = 0.39).

CONCLUSION

Early enteral fluid resuscitation is safe and effective for in severe pancreatitis. But this conclusion needs to be verified by more additional multi-centre randomized controlled trials with large samples.

Wernicke's encephalopathy after acute pancreatitis with upper gastrointestinal obstruction: A case report and literature review

A 42-year-old female was admitted with upper abdominal pain. Imaging studies and laboratory tests were performed to consider acute lipogenic pancreatitis. After symptomatic treatment, her abdominal pain was significantly relieved. However, the patient was accompanied by upper gastrointestinal obstruction, which was gradually relieved after long-term fasting, gastrointestinal decompression, and fluid rehydration. The patient developed dizziness and ataxia, which worsened. Cranial magnetic resonance imaging (MRI) indicated patchy abnormal signal shadows in the bilateral thalami and dorsal brainstem and suggested metabolic encephalopathy. Wernicke's encephalopathy (WE) was the initial diagnosis of suspicion, adequate vitamin B1 was immediately replenished until the complete resolution of symptoms, and the patient made a rapid and dramatic recovery.

Diagnosis, severity stratification and management of adult acute pancreatitis-current evidence and controversies

Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.