Correlates of morbidity and mortality in severe necrotizing pancreatitis

Percutaneous Catheter Drainage in Acute Infected Necrotizing Pancreatitis: A Real-World Experience at a Tertiary Care Hospital in North India

Introduction

Open necrosectomy in acute infected necrotizing pancreatitis is associated with very high mortality and morbidity. Moreover, if it is performed before four weeks, the benefits are limited. In this study, we evaluated the safety and efficacy of percutaneous catheter drainage (PCD) in patients with acute infected necrotizing pancreatitis.

Methods

It was a single-center, observational study, where all consecutive patients with proven or probable infected acute necrotizing pancreatitis in whom PCD was performed were studied. The patients who failed to respond to PCD underwent open necrosectomy. Baseline characteristics and the outcome of all included patients, including complications of PCD, were studied.

Results

A total of 46 patients (males=36, females=10) underwent PCD over a period of 18 months. Fifteen (32.60%) patients succumbed to their illness. PCD benefitted a total of 31 (67.39%) patients; in 17 (36.95%) patients, it worked as a standalone therapy, while in 14 (30.43%) patients, additional surgery was required where it helped to delay the surgery. Median days at which PCD and surgery were performed were 17.5 days (range: 2-28 days) and 33 days (range: 7-70 days), respectively. Lower mean arterial pressure at presentation, presence of multiorgan failure, more than 50% necrosis, higher baseline creatinine and bilirubin levels, and an early surgery were markers of increased mortality. Three (6.5%) patients had PCD-related complications, out of which only one required active intervention.

Conclusion

PCD in infected acute pancreatic necrosis is safe and effective. In one-third of the patients, it worked as standalone therapy, and in the rest it delayed the surgery beyond four weeks, thereby preventing the complications associated with early aggressive debridement.

CCCTC-binding factor-mediated microRNA-340-5p suppression aggravates myocardial injury in rats with severe acute pancreatitis through activation of the HMGB1/TLR4 axis

BACKGROUND

Severe acute pancreatitis (SAP) is a life-threatening disorder associated with multisystem organ failure. This study aimed to investigate the function of high mobility group box 1 (HMGB1) in SAP-induced myocardial injury.

METHODS

A rat model with SAP was induced. The pathological changes in rat pancreatic and cardiac tissues were examined by HE staining. Cardiomyocyte apoptosis in rat cardiac tissues, and the serum levels of myocardial injury markers and pro-inflammatory cytokines were examined. Rat primary cardiomyocytes were treated with H₂O₂ for in vitro experiments. The regulatory molecules of HMGB1 were predicted by bioinformatics analysis. Altered expression of HMGB1, microRNA (miR)-340-5p and CCCTC-binding factor (CTCF) was introduced in rats or cells to investigate their roles in myocardial injury.

RESULTS

CTCF and HMGB1 were highly expressed but miR-340-5p was poorly expressed in cardiac tissues of rats with SAP. HMGB1 silencing reduced toll-like receptor 4 (TLR4) expression to promote proliferation and reduce apoptosis of H₂O₂-treated cardiomyocytes. miR-340-5p targeted HMGB1 mRNA, while CTCF suppressed miR-340-5p transcription. CTCF upregulation or miR-340-5p downregulation blocked the effects of HMGB1 silencing on cardiomyocytes. In vivo, CTCF silencing alleviated injury in rat pancreatic and cardiac tissues and reduced the expression of creatine kinase-MB (CK-MB), lactic dehydrogenase, interleukin (IL)-1β, IL-6 and tumor necrosis factor-α (TNF-α) in rat serum. But further overexpression of HMGB1 or inhibition of miR-340-5p aggravated the symptoms in rats.

CONCLUSION

This study demonstrated that CTCF reduces transcription of miR-340-5p to promote HMGB1 expression, which activates TLR4 expression and promotes myocardial injury in rats with SAP.

Streptokinase irrigation through a percutaneous catheter helps decrease the need for necrosectomy and reduces mortality in necrotizing pancreatitis as part of a step-up approach

BACKGROUND

Percutaneous catheter drainage in pancreatic necrosis with a predominant solid component has a reduced success rate. To improve the efficacy of percutaneous catheter drainage, we used streptokinase in the irrigation fluid in the present study.

METHODS

In this retrospective analysis of 4 prospective randomized studies performed at our center from 2014 to 2019, 108 patients were evaluated. We assessed the safety, feasibility, and efficacy of streptokinase irrigation compared to saline irrigation. Data were also analyzed between 50,000 IU and 150,000 IU streptokinase.

RESULTS

There were 53 patients in the streptokinase irrigation group and 55 in the saline irrigation group, and both groups were comparable in terms of age, sex, etiology, APACHE II score, and percutaneous catheter drainage characteristics. The modified computerised tomography severity index and modified Marshall score at the onset of pain were significantly higher in the streptokinase group. Sepsis reversal was significantly higher in the streptokinase group (75% vs 36%), and the need for necrosectomy (34% vs 54%) was also lower in the streptokinase group. Mortality was lower in the streptokinase group than in the saline group (32% vs 40%). The incidence of bleeding in the streptokinase group was lower than that in the saline group (7% vs 18%). A higher dose of streptokinase (150,000 IU) resulted in lower rates of necrosectomy, bleeding, and mortality compared to those with 50,000 IU streptokinase.

CONCLUSION

Significant reductions in the need for surgery and sepsis reversal were noted in the streptokinase group. The results using 150,000 IU streptokinase were superior to those using 50,000 IU streptokinase.

Porous SiO2 -coated ultrasmall selenium particles nanospheres attenuate cerulein-induce acute pancreatitis in mice by downregulating oxidative stress

OBJECTIVE

To investigate the potential therapeutic role of porous SiO₂ -coated ultrasmall selenium particles nanospheres (Se@SiO₂ nanospheres) pretreatment in acute pancreatitis (AP) and to investigate the related mechanism.

METHODS

C57BL/6 mice were randomized to the normal control (CON) group, the AP (induced by cerulein injection) (CAE) group, and AP pretreated with Se@SiO₂ nanocomposites at 1 and 2 mg/kg (CAE + 1 or 2 mg/kg Se@SiO₂ ) groups, respectively. Serum levels of amylase and lipase, inflammatory cytokines (interleukin [IL]-6, IL-1β and tumor necrosis factor [TNF]-α), alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood urea nitrogen (BUN), and creatinine (Cr) were measured, and histopathology was performed to examine the tissue samples of the pancreas, lungs, kidneys and liver. Immunofluorescence assay of reactive oxygen species (ROS), myeloperoxidase (MPO) and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling were conducted, and levels of MPO, malondialdehyde, superoxide dismutase and glutathione were evaluated. Finally, Western blot analysis was used to evaluate protein expressions of Nrf2, HO-1, NQO1, TLR4, MyD88 and p-p65 in pancreatic tissue.

RESULTS

Se@SiO₂ nanospheres alleviated pathological damage to the pancreas, and reduced pancreatic enzymes and inflammatory cytokines. Injury to other organs such as the liver, lungs and kidneys was also alleviated, as indicated by decreased ALT, AST, BUN, and Cr levels as well as improved histopathology. Moreover, Se@SiO₂ nanospheres reduced oxidative stress, and ultimately inhibited TLR4/ MyD88/p-p65 pathway and increased the protein expressions of NQO1, Nrf2, and HO-1.

CONCLUSION

Se@SiO₂ nanospheres may alleviate AP by relieving oxidative stress and targeting the TLR4/Myd88/p-p65 and NQO1/Nrf2/HO-1 pathways.

miR-29a-3p transferred by mesenchymal stem cells-derived extracellular vesicles protects against myocardial injury after severe acute pancreatitis

AIMS

Acute pancreatitis (AP) is an inflammatory disease of the pancreas that may affect local tissues or remote organ systems, while severe acute pancreatitis (SAP) is a life-threatening disorder associated with multiple organ failure. In this investigation, we set about to determine whether microRNA-29a-3p (miR-29a-3p) carried by mesenchymal stem cell (MSCs)-derived extracellular vesicles (EVs) affects the myocardial injury during SAP.

MAIN METHODS

EVs were isolated from MSCs of rat bone marrow by differential centrifugation. An SAP rat model was developed and treated with MSCs-EVs and/or alteration of miR-29a-3p and HMGB1 expression, followed by assessment of the rats' cardiac function and inflammation. Next, cardiomyocytes H9C2 were co-cultured with MSC-EVs and internalization of EVs was evaluated, followed by evaluation of whether EVs could transmit miR-29a-3p cargos into H9C2 cells and affect their biological functions.

KEY FINDINGS

EVs derived from MSCs were observed to protect against SAP-induced myocardial injury. In SAP-induced rats, miR-29a-3p was under-expressed in myocardial tissues. In addition, we also confirmed that miR-29a-3p could be transferred into the H9C2 cardiomyocytes by MSC-derived EVs, which downregulated the expression of inflammatory markers and improve cardiac function to attenuate myocardial injury. Furthermore, miR-29a-3p inhibited the expression of HMGB1 to downregulate TLR4 expression and further inactivate the Akt signaling pathway.

SIGNIFICANCE

These findings support the cardioprotective action of miR-29a-3p transmitted by MSCs-derived EVs in SAP-induced myocardial injury via downregulation of the HMGB1/TLR4/Akt axis, highlighting a promising target for the EV-based therapy for SAP.

Outcomes of Endoscopic and Surgical Pancreatic Necrosectomy: A Single Institution Experience

Pancreatic necrosis can be managed conservatively; however, infection of pancreatic necrosis usually dictates more aggressive management. Our study aimed to assess the outcomes of open pancreatic necrosectomy (OPN) and endoscopic pancreatic necrosectomy (EPN) in a single center. Data from patients undergoing pancreatic necrosectomy at the Geisinger Medical Center from January 1, 2007, to April 25, 2016, were collected and retrospectively analyzed. Cohorts were composed of EPN (n = 22) and OPN (n = 34) groups. The prevalence of preoperative respiratory failure, septic shock, and multiorgan dysfunction syndrome was higher in the OPN group. The OPN group presented with a higher Bedside Index Severity in Acute Pancreatitis score. Postoperative abscess, persistent kidney dysfunction, and death were more frequent in the OPN group. The EPN group had a higher read-mission rate. The results of the univariate analysis for complication and mortality demonstrated that higher mortality and persistent kidney dysfunction were associated with the procedure type, specifically OPN and with a higher Bedside Index Severity in Acute Pancreatitis score. Patients who presented with higher severity of disease underwent an OPN, whereas EPN often was performed successfully in a more benign clinical setting. However, patients with infected necrosis are served best in a tertiary medical facility where multiple treatment modalities are available.

Apigenin Exerts Anti-inflammatory Effects in an Experimental Model of Acute Pancreatitis by Down-regulating TNF-α

BACKGROUND/AIM

This study investigated the anti-inflammatory effect of apigenin in an experimental model of acute pancreatitis. Inflammatory response was reflected by tissue expression of the cytokine TNF-α coupled with histological examination.

MATERIALS AND METHODS

Wistar rats were divided into three groups: Sham-group animals underwent laparotomy only, without any other interventions. Control-group animals underwent laparotomy and bilio-pancreatic duct ligation to induce pancreatitis without apigenin administration. Apigenin group animals were further treated with apigenin. Euthanasia was performed at 6, 12, 24, 48 and 72 h post-operatively.

RESULTS

Over-expression of TNF-α in relation to postoperative time was observed in the control group (p<0.001). In the apigenin group, under-expression of TNF-α in relation to postoperative time was observed (p<0.013). At 72 h, apigenin reduced pancreatic TNF-α expression and prevented pancreatic necrosis.

CONCLUSION

Apigenin slows progression and reduces severity of acute pancreatitis. Apigenin may serve as an adjunct to a more successful therapeutic strategy in acute pancreatitis.

Health-related quality of life and long-term outcomes after endoscopic therapy for walled-off pancreatic necrosis

BACKGROUND AND AIM

Walled-off pancreatic necrosis (WON) frequently develops after necrotizing pancreatitis. Endoscopic drainage has become the preferred modality for symptomatic or infected WON. The aim of the present study was to assess health-related quality of life (HR-QOL) and long-term outcomes in patients undergoing endoscopic drainage for WON.

METHODS

Patients undergoing endoscopic drainage of WON from January 2006 to May 2016 were identified. Data recorded included demographic information, and the incidence of long-term sequelae including pancreatic endocrine and exocrine insufficiency. Attempts were made to contact all patients. HR-QOL was assessed using the SF-36 questionnaire.

RESULTS

Eighty patients were analyzed, 41 (51.3%) of whom completed the SF-36. One-year all-cause mortality was 6.2%, and disease-related mortality was 3.7%. A notable proportion of patients developed exocrine insufficiency (32.5%), endocrine insufficiency (27.7%), and long-term opiate use (42.5%). Development of exocrine insufficiency was predictive of lower total SF-36 scores (P = 0.016). Patients with WON had better HR-QOL compared with cohorts of irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). In patients developing exocrine insufficiency versus healthy controls, poorer scores in the physical role (P < 0.001), general health (P < 0.001), vitality (P = 0.001), and emotional role (P = 0.029) domains were observed. Exocrine insufficiency patients had better HR-QOL than the IBS and IBD cohorts, although these differences were less pronounced.

CONCLUSION

After undergoing endoscopic drainage for WON, patients have relatively preserved HR-QOL. The subset of patients that develop exocrine insufficiency have significantly poorer HR-QOL compared to healthy controls, although not to the degree of chronic gastrointestinal disorders such as IBS and IBD.

Outcome of patients with acute pancreatitis requiring intensive care admission: A retrospective study from a tertiary care center of Pakistan

Background and Objective

Acute pancreatitis (AP) is an inflammatory disease. Patients presenting with severe disease may require intensive care unit (ICU) admission. Factors predicting mortality and morbidity need to be identified for improving outcome. The objective of this study was to see the outcome of these patient presented to single center over a period of ten years. The secondary objective was to identify the factors responsible for adverse outcome.

Methods

The medical records of adult patients from year 2006 to 2016 requiring ICU admission for AP were reviewed retrospectively. The data was collected on the predesigned Performa for patient's demographic, etiology, severity of disease and reason of ICU referral. Besides this physiological and biochemical parameters at time of arrival in ICU were also recorded. Management aspects related to disease course including the ICU related complications were also recorded. The outcome was predicted on the basis of mortality and length of stay (LOS) in ICU and hospital.

Results

Total 85 patients were identified of having AP requiring ICU admission. 56% of these cases were referred from emergency. Mean Ranson score (RS) was 2.6 and 2.7, at and after 48 hours of admission. Necrosis was present in 48% of cases. Mean APACHE-II score was 23. Sepsis was the commonest complication in ICU. The median LOS in ICU and hospital was six and 12 days respectively. The overall hospital mortality was 52%, out of which 82% died in ICU. RS at admission and APACHE were correlated well with outcome. Similarly associations of factors like need of vasopressors, ARDS, pneumonia, sepsis and AKI requiring intervention were also related to mortality. Likewise development of necrosis or intra-abdominal hypertension showed increased mortality. Biochemical parameters serum blood urea nitrogen (BUN), P_H and serum glutamic-oxaloacetic transaminase were also directly linked to adverse outcome.

Conclusion

AP patients requiring ICU admission represent severe form of disease. There is a need to develop protocol based care, which should be started immediately after hospital admission. This should have special focus on fluid resuscitation and nutritional therapy. Role of simple bed site parameters like BUN needs to be evaluated.

Bacteriological profile of intra-abdominal infections in a tertiary care hospital

BACKGROUND AND OBJECTIVES

Intra-abdominal infections (IAIs) include a wide spectrum of pathological conditions, ranging from uncomplicated appendicitis to fecal peritonitis .The resulting infections should be diagnosed early and treated based on the organism isolated and its susceptibility. In this study the bacteriological profile and antimicrobial resistance pattern of intra-abdominal infections was analyzed.

MATERIALS AND METHODS

A retrospective analysis of samples received from 119 cases of intra-abdominal infections in our Institute from January 2015 to December 2017 was analyzed. Patients with primary peritonitis from cirrhosis or ascites were not included in the study. The specimens were primarily processed, as per standard methods. Identification and antimicrobial susceptibility testing was done by the Vitek-2 system. Anaerobic culture was performed on 5% sheep blood agar plates and incubated in GEN bag anaerobic pouches.

RESULTS

In our study perforative peritonitis 43/119 (36.1%) was predominant IAI followed by acute pancreatitis 14/119 (11.7%) and pancreatic necrosis 12/119 (10%). Microbial growth was observed in 66.3% (79/119) of the cases and combined infections were observed in14/119 (11.7%) of the cases. Escherichia coli was the predominant organism isolated in 58/119 (40.8%), out of which 41/58 (70.6%) were ESBL producers and 16/58 (27.5%) were multi drug resistant isolates. Klebsiella pneumoniae was isolated from 11/119 (9.2%) cases out of which 8/11 (72.7%) were ESBL and 3/11 (27.2%) were multidrug resistant isolates. Post-operative complications was observed in 12/119 (10%) patients with mortality in 15/119 (12.6%) patients.

CONCLUSION

Early diagnosis and appropriate management of the infections will help to prevent the morbidity and mortality associated with these infections.

A 44-year-old, Caucasian, male nonsmoker with worsening difficulty in breathing and decreased exercise tolerance

Can you diagnose this patient and identify the uncommon cause of his illness? http://ow.ly/t4nX30bzJFz.

Severe acute pancreatitis: pathogenesis, diagnosis and surgical management

BACKGROUND

Severe acute pancreatitis is a subtype of acute pancreatitis, associated with multiple organ failure and systemic inflammatory response syndrome. In this qualitative review we looked at the principles of pathogenesis, classification and surgical management of severe acute pancreatitis. We also looked at the current shift in paradigm in the management of severe acute pancreatitis since the guideline developed by the British Society of Gastroenterology.

DATA SOURCES

Studies published between 1st January 1991 and 31st December 2015 were identified with PubMed, MEDLINE, EMBASE and Google Scholar online search engines using the following Medical Subject Headings: "acute pancreatitis, necrosis, mortality, pathogenesis, incidence" and the terms "open necrosectomy and minimally invasive necrosectomy". The National Institute of Clinical Excellence (NICE) Guidelines were also included in our study. Inclusion criteria for our clinical review included established guidelines, randomized controlled trials and non-randomized controlled trials with a follow-up duration of more than 6 weeks.

RESULTS

The incidence of severe acute pancreatitis within the UK is significantly rising and pathogenetic theories are still controversial. In developed countries, the most common cause is biliary calculi. The British Society of Gastroenterology, acknowledges the Revised Atlanta criteria for prediction of severity. A newer Determinant-based system has been developed. The principle of surgical management of acute necrotizing pancreatitis requires intensive care management, identifying infection and if indicated, debridement of any infected necrotic area. The current procedures opted for include standard surgical open necrosectomy, endoscopic necrosectomy and minimally invasive necrosectomy. The current paradigm is shifting towards a step-up approach.

CONCLUSIONS

Severe acute pancreatitis is still a subject of grey areas in its surgical management even though new studies have been recorded since the origin of the latest UK guidelines for management of severe acute pancreatitis.

Current concepts in the management of acute pancreatitis

Guidelines for the management of acute pancreatitis (AP) are based on the Western experience, which may be difficult to extrapolate in India due to socioeconomic constraints. Hence, modifications based on the available resources and referral patterns should be introduced so as to ensure appropriate care. We reviewed the current literature on the management of AP available in English on Medline and proposed guidelines locally applicable. Patients of AP presenting with systemic inflammatory response syndrome are at risk of moderate-severe pancreatitis and hence, should be referred to a tertiary center early. The vast majority of patients with AP have mild disease and can be managed at smaller centers. Early aggressive fluid resuscitation with controlled fluid expansion, early enteral nutrition, and culture-directed antibiotics improve outcomes in AP. Infected pancreatic necrosis should be managed in a tertiary care hospital within a multidisciplinary setup. The "step up" approach involving antibiotics, percutaneous drainage, and minimally invasive necrosectomy instituted sequentially based on clinical response has improved the outcomes in this subgroup of patients.