Clinical Outcomes of Acute Pancreatitis in Patients with Cirrhosis According to Liver Disease Severity Scores

BACKGROUND

Literature on acute pancreatitis (AP) outcomes in patients with cirrhosis is limited. We aim to investigate the mortality and morbidity of AP in patients with cirrhosis.

METHODS

We conducted a retrospective cohort study, and propensity score matching was done to match cirrhotic with non-cirrhotic patients on a 1:2 basis. Outcomes included inpatient mortality, organs failure, systemic inflammatory response syndrome, and length of hospital stay. We performed subgroup analysis of cirrhotics according to Child-Pugh and MELD scores. Multivariable logistic regression models were tested.

RESULTS

From 819 AP patients, cirrhosis prevalence was 4.9% (40). There was no significant difference between cirrhotics and non-cirrhotics for inpatient mortality (7.5% vs. 1.3%, p = 0.1), severe AP (17.5% vs. 7.5%), shock (7.9% vs. 3%), respiratory failure (10% vs. 3.8%), need for intensive care unit (15% vs. 6.3%), systemic inflammatory response syndrome (SIRS) on admission (22.5% vs. 32.5%), and SIRS on day 2 (25% vs. 15%). Cirrhotics had similar rates of pancreatic necrosis, ileus, BISAP score, Marshall score, admission hematocrit, BUN, and hospital length of stay. Finally, cirrhotics who had severe AP, required ICU, and/or die in-hospital appeared to have more severe liver diseases (Child-C, higher MELD score > 17) and had lower AP severity scores (BISAP < 3, Marshall scores < 2).

CONCLUSION

In our study, cirrhotics hospitalized with AP had similar morbidity and mortality when compared to non-cirrhotics.

Appraisal of the diagnostic procedures of acute pancreatitis in the guidelines

OBJECTIVES

The purpose of this study was to comprehensively assess the heterogeneity of procedures in the diagnostic guidelines for acute pancreatitis and to identify gaps limiting knowledge in diagnosing this disease.

METHODS

A systematic search of a number of databases was performed to determine the guidelines for the diagnosis of acute pancreatitis in patients with severe pancreatitis. The guidelines for the diagnosis of severe pancreatitis were evaluated by AGREE II. The Measurement Scale of Rate of Agreement (MSRA) was used to assess the guidelines (2015-2020) and extract evidence supporting these recommendations for analysis.

RESULTS

Seven diagnostic guidelines for acute pancreatitis were included. Only the 2019 WSES Guidelines for the Management of Severe Acute Pancreatitis and the Japanese Guidelines for the Management of Acute Pancreatitis: Japanese Guidelines 2015 had a total score of more than 60%, which is worthy of clinical recommendation. The average scores of the Scope and Purpose domain and the Clarity and Expression domain were the highest at 71.62% and 75.59%, respectively, while the average score of the Applicability area was the lowest at 16.67%. The included guidelines were further analyzed to determine the heterogeneity of the diagnosis of acute pancreatitis. The main reasons for the heterogeneity were the citation of low-quality evidence, the presence of far too many indicators for the classification of acute pancreatitis, unclear depictions of the standard, and poorly comprehensive recommendations for the diagnosis of the aetiology in the primary diagnosis of acute pancreatitis, the severity classification, the aetiological diagnosis, and the diagnosis of comorbidities.

CONCLUSIONS

The quality of different diagnostic guidelines for severe pancreatitis is uneven. The recommendations are largely based on low-quality evidence, and the guidelines still have much room for improvement to reach a high level of quality. The diagnostic procedures for acute pancreatitis vary widely in different guidelines. There are large differences between them, and resolving the abovementioned reasons would be a very wise choice for guideline developers to revise and upgrade the guidelines in the future.

Management of Severe Acute Pancreatitis

Purpose of review

There have been significant advancements in different aspects of management of severe acute pancreatitis (SAP). Our review of the most recent literature focuses on severity prediction, fluid resuscitation, analgesic administration, nutrition, and endoscopic intervention for SAP and its extra-pancreatic complications.

Recent findings

Recent studies on serum cytokines for the prediction of SAP have shown superior prognostic performance when compared with conventional laboratory tests and clinical scoring systems. In patients with established SAP and vascular leak syndrome, intravenous fluids should be administered with caution to prevent intra-abdominal hypertension and volume overload. Endoscopic retrograde cholangiopancreatography improves outcomes only in AP patients with suspected cholangitis. Early enteral tube-feeding does not appear to be superior to on-demand oral feeding. Abdominal compartment syndrome is a highly lethal complication of SAP that requires percutaneous drainage or decompressive laparotomy. Endoscopic transmural drainage followed by necrosectomy (i.e., “step-up approach”) is the treatment strategy of choice in patients with symptomatic or infected walled-off pancreatic necrosis.

Summary

SAP is a complex clinical syndrome associated with a high mortality rate. Early prediction of SAP remains challenging due to the limited accuracy of the available prediction tools. Early fluid resuscitation, organ support, enteral nutrition, and prevention of/or prompt recognition of abdominal compartment syndrome remain cornerstones of its management. A step-up, minimally invasive drainage/debridement is the preferred approach for patients with infected pancreatic necrosis.

Consensus and controversy among severe pancreatitis surgery guidelines: a guideline evaluation based on the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool

The purpose of this study was to systematically evaluate guidelines for surgery in patients with severe pancreatitis and to identify gaps limiting evidence-based medicine practice. A systematic search of databases and related websites was conducted to identify surgical guidelines for patients with severe pancreatitis. The quality of the included guidelines was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The similarities among key recommendations were compared, and the evidence supporting them was extracted and analysed. Seven surgical guidelines for patients with severe pancreatitis were included. Only two guidelines, those of the World Society of Emergency Surgery (WSES) and the European Society of Gastrointestinal Endoscopy (ESGE), scored more than 60% for overall quality and were worthy of clinical recommendation. We found that the quality of the severe acute pancreatitis surgical guidelines have much room for improvement, especially in the field of application, the participation of stakeholders and editorial independence. The heterogeneity and causes of surgical recommendations were further analysed, and the latest evidence was retrieved. It was found that the surgical guidelines for severe pancreatitis lacked high-quality evidence, some of the recommendations were controversial, and evidence citation was unreasonable. The quality of surgical guidelines for patients with severe pancreatitis varies widely. In the past 5 years, the key recommendations of the surgical guidelines for severe pancreatitis have been somewhat consistent and controversial, and improvement in these existing problems and controversies will be an effective way for developers to upgrade the surgical guidelines for severe pancreatitis.

Association of visceral adipose tissue on the incidence and severity of acute pancreatitis: A systematic review

BACKGROUND

With the rising prevalence of obesity, there is a plethora of literature discussing the relationship between obesity and acute pancreatitis (AP). Evidence has shown a possible correlation between visceral adipose tissue (VAT) and AP incidence and severity. This systematic review explores these associations.

METHODS

Eligible articles were searched and retrieved using Medline and Embase databases. Clinical studies evaluating the impact of VAT as a risk factor for AP and the association of the severity of AP and VAT were included.

RESULTS

Eleven studies, with a total of 2529 individuals were reviewed. Nine studies showed a statistically significant association between VAT and the severity of AP. Only four studies found VAT to be a risk factor for acute pancreatitis. Two studies showed VAT to be associated with an increased risk of local complications and two studies showed a correlation between VAT and mortality.

CONCLUSION

This is the first systematic review conducted to study the association between VAT and AP. The existing body of evidence demonstrates that VAT has a clinically relevant impact and is an important prognostic indicator of the severity of AP. However, it has not shown to be an independent risk factor to the risk of developing AP. The impact of VAT on the course and outcome of AP needs to be profoundly explored to confirm these findings which may fuel earlier management and better define the prognosis of patients with AP. VAT may need to be incorporated into prognostic scores of AP to improve accuracy.

[Metagenomic Sequencing for Pathogens Detection in a Critically Ill Patient]

OBJECTIVE

To detect pathogens in a critically ill patient using metagenomic sequencing.

METHODS

A critically ill patient with severe acute pancreatitis suffered from abdominal pain and progressed into unconsciousness. Tissue smear, culture, automated biochemical identification and antibiotic susceptibility test, viral load determination by real-time fluorescence quantitative PCR, and immunohistochemical pathological tests were performed to detect pathogens, in addition to metagenomic sequencing based on the BGISEQ-100 high throughput sequencing platform. The sequences exclusive of host sequences were searched in the microbial genome database including viruses, bacteria, fungi and parasites.

RESULTS

The patient was infected with methicillin-resistant Staphylococcus aureus, carbapenem-resistant Klebsiella pneumoniae and carbapenem-resistant Acinetobacter baumannii, verified by both the routine methods and the metagenomic sequencing. The metagenomic sequencing also detected cytomegalovirus (CMV) with a turn-around time of 5 days. Real-time fluorescent quantitative PCR confirmed 189 000 copies/mL CMV load.

CONCLUSION

In this case, three species of bacteria and one virus were detected by metagenomic sequencing quickly and accurately. Metagenomic sequencing may be helpful for diagnosing infectious diseases in critically ill patients.

Exocrine Pancreatic Insufficiency Following Acute Pancreatitis: Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

The epidemiology of exocrine pancreatic insufficiency (EPI) after acute pancreatitis (AP) is uncertain. We sought to determine the prevalence, progression, etiology and pancreatic enzyme replacement therapy (PERT) requirements for EPI during follow-up of AP by systematic review and meta-analysis.

METHODS

Scopus, Medline and Embase were searched for prospective observational studies or randomized clinical trials (RCTs) of PERT reporting EPI during the first admission (between the start of oral refeeding and before discharge) or follow-up (≥ 1 month of discharge) for AP in adults. EPI was diagnosed by direct and/or indirect laboratory exocrine pancreatic function tests.

RESULTS

Quantitative data were analyzed from 370 patients studied during admission (10 studies) and 1795 patients during follow-up (39 studies). The pooled prevalence of EPI during admission was 62% (95% confidence interval: 39-82%), decreasing significantly during follow-up to 35% (27-43%; risk difference: - 0.34, - 0.53 to - 0.14). There was a two-fold increase in the prevalence of EPI with severe compared with mild AP, and it was higher in patients with pancreatic necrosis and those with an alcohol etiology. The prevalence decreased during recovery, but persisted in a third of patients. There was no statistically significant difference between EPI and new-onset pre-diabetes/diabetes (risk difference: 0.8, 0.7-1.1, P = 0.33) in studies reporting both. Sensitivity analysis showed fecal elastase-1 assay detected significantly fewer patients with EPI than other tests.

CONCLUSIONS

The prevalence of EPI during admission and follow-up is substantial in patients with a first attack of AP. Unanswered questions remain about the way this is managed, and further RCTs are indicated.

Pediatric Pancreatitis-Molecular Mechanisms and Management

Pediatric pancreatitis is an emerging field with an increasing incidence of disease. Management of pediatric pancreatitis is understudied and, therefore, extrapolated from adult studies (although the etiologies are different). There is evidence that feeding is safe in mild acute pancreatitis in children without increased pain or length of stay. Studies are needed to predict course of the disease, disease severity, and risk of chronic pancreatitis in children.

Efficacy of ulinastatin combined with octreotide for patients with severe pancreatitis: Effect on clinical symptoms, serological markers and safety

AIM

To evaluate the efficacy of ulinastatin combined with octreotide in the treatment of severe pancreatitis and the effect on clinical symptoms, serological indicators and safety.

METHODS

Ninety-four patients with severe pancreatitis who were treated at Guangdong Provincial People's Hospital from February 2016 to January 2018 were randomly divided into an experimental group (46 cases) and a reference group (48 cases). The reference group was treated with octreotide alone, and the experimental group was treated with octreotide combined with ulinastatin. The treatment lasted 2 wk in both groups. Clinical curative effect, serological parameters, amylase, intestinal mucosal function index and complications were compared between the two groups.

RESULTS

The total effective rate in the experimental group was 95.65%, which was significantly higher than that of the reference group (83.33%; P < 0.05). Time to disappearance of abdominal pain, nausea, vomiting and peritoneal irritation, time to first defecation, time to bowel sound recovery and hospital stay in the experimental group were significantly shorter than those of the reference group (P < 0.05), and the mortality rate was significantly lower than that of the reference group (P < 0.05). There was no significant difference in serum C-reactive protein, tumor necrosis factor-α, interleukin-18, interleukin-6, blood amylase, urine amylase, occludin, diamine oxidase or endotoxin levels between the two groups before treatment (P > 0.05). After treatment intervention, the above-mentioned indicators improved significantly in both groups, and the experimental group improved significantly better than those of the reference group (P < 0.05). The incidence of acute respiratory distress syndrome, acute renal failure and shock in the experimental group was significantly lower than that of the reference group (P < 0.05). There was no significant difference in the incidence of pancreatic encephalopathy syndrome or metabolic dysfunction between the two groups (P > 0.05).

CONCLUSION

Ulinastatin combined with octreotide has good clinical effects in severe pancreatitis patients and can improve treatment efficiency, clinical symptoms and serological indicators, protect the intestinal mucosal function, and reduce the incidence of complications.

Nursing care of elderly patients with drug-induced severe pancreatitis by continuous closed high flow peritoneal lavage combined with continuous blood purification

AIM

To explore the nursing effect of closed high-flow peritoneal lavage combined with continuous blood purification in elderly patients with drug-induced severe pancreatitis.

METHODS

A total of 50 elderly patients with drug-induced severe acute pancreatitis who received continuous closed high flow peritoneal lavage combined with blood purification between January 2017 and January 2018 at our emergency internal medicine department were enrolled as an experimental group. Fifty elderly patients with drug-induced severe pancreatitis who received basic nursing measures only were included as a control group. The average frequency of complications, number of treatment cycles, number of cycles required for serum amylase recovery, and duration of abdominal pain in the two groups were statistically analyzed. The changes of liver and kidney function, APACHE Ⅱ, and CTSI score were also recorded and compared.

RESULTS

The average frequency of complications, number of treatment cycles, number of cycles required for serum amylase recovery, and duration of abdominal pain were significantly lower in the experimental group than in the control group (P < 0.05). The liver and kidney function of the patients in the experimental group were obviously superior to those before treatment (P < 0.05), while the difference in the control group did not reach statistical significance. The APACHE Ⅱ and CTSI scores in the experimental group were significantly lower than those in the control group (P < 0.05).

CONCLUSION

Continuous closed high-flow peritoneal lavage combined with blood purification can effectively reduce symptoms, shorten the treatment cycle, and improve prognosis in elderly patients with drug-induced severe acute pancreatitis.

Alprostadil combined with somatostatin for treatment of severe acute pancreatitis: Clinical efficacy and impact on inflammatory factors

AIM

To observe the clinical efficacy of alprostadil combined with somatostatin in the treatment of severe pancreatitis (SAP) and the influence on inflammatory factors.

METHODS

Eighty two patients with SAP treated from April 2013 to May 2017 were enrolled in this study. They were randomly divided into either an observation group or a control group. Both groups were given routine treatments and alprostadil, and the observation group was additionally given somatostatin. After 2 wk of therapy, clinical efficacy, symptom remission time, serum inflammatory factor levels, adverse reaction rate, and mortality rate of the two groups were compared.

RESULTS

The total effective rate was 92.68% (38/41) in the observation group and 75.61% (31/41) in the control group, and there was a significant difference between them (χ² = 4.479, P < 0.05). Times to recovery of bowel pain, intestinal function, and blood amylase as well as hospital stay were significantly shorter in the observation group than in the control group (P < 0.05). The levels of white blood count (WBC), C-reactive protein (CRP), amylase (AMY), alanine transaminase (ALT), alanine transaminase (AST), and creatinine (Cr) in the observation group were significantly lower than those in the control group at 7 d and 14 d after treatment (P < 0.05). The levels of endotoxin, TNF-α, IL-6, and IL-1β in the observation group were significantly lower than those in the control group (P < 0.05). The mortality rate in the observation group (2.44%, 1/41) was significantly lower than that in the control group (17.07%, 7/41) (χ² = 4.986, P < 0.05).

CONCLUSION

Alprostadil combined with somatostatin in the treatment of severe pancreatitis has obvious efficacy and can reduce symptoms and the inflammatory response quickly.

Combined totally mini-invasive approach in necrotizing pancreatitis: a case report and systematic literature review

BACKGROUND

Currently, both the step-up approach, combining percutaneous drainage (PD) and video-assisted retroperitoneal debridement (VARD), and endoscopic transgastric necrosectomy (ETN) are mini-invasive techniques for infected necrosis in severe acute pancreatitis. A combination of these approaches could maximize the management of necrotizing pancreatitis, conjugating the benefits from both the experiences. However, reporting of this combined strategy is anecdotal. This is the first reported case of severe necrotizing pancreatitis complicated by biliary fistula treated by a combination of ETN, PD, VARD, and endoscopic biliary stenting. Moreover, a systematic literature review of comparative studies on minimally invasive techniques in necrotizing pancreatitis has been provided.

CASE PRESENTATION

A 59-year-old patient was referred to our center for acute necrotizing pancreatitis associated with multi-organ failure. No invasive procedures were attempted in the first month from the onset: enteral feeding by a naso-duodenal tube was started, and antibiotics were administered to control sepsis. After 4 weeks, CT scans showed a central walled-off pancreatic necrosis (WOPN) of pancreatic head communicating bilateral retroperitoneal collections. ETN was performed, and bile leakage was found at the right margin of the WOPN. Endoscopic retrograde cholangiopancreatography confirmed the presence of a choledocal fistula within the WOPN, and a biliary stent was placed. An ultrasound-guided PD was performed on the left retroperitoneal collection. Due to the subsequent repeated onset of septic shocks and the evidence of size increase of the right retroperitoneal collection, a VARD was decided. The CT scans documented the resolution of all the collections, and the patient promptly recovered from sepsis. After 6 months, the patient is in good clinical condition.

CONCLUSIONS

No mini-invasive technique has demonstrated significantly better outcomes over the others, and each technique has specific indications, advantages, and pitfalls. Indeed, ETN could be suitable for central WOPNs, while VARD or PD could be suggested for lateral collections. A combination of different approaches is feasible and could significantly optimize the clinical management in critically ill patients affected by complicated necrotizing pancreatitis.

Clinical effects of anisodamine combined with Xuebijing in treatment of severe pancreatitis

AIM: To investigate the clinical effects of anisodamine combined with Xuebijing in the treatment of severe pancreatitis.

METHODS: One hundred and forty-six patients with severe pancreatitis treated at Wuhan integrated Chinese and Western Medicine Hospital from October 2011 to December 2014 were randomly divided into two groups. Seventy-three patients were treated with anisodamine alone as a control group, and 73 patients were treated with anisodamine combined with Xuebijing as an observation group. Therapeutic effects were compared between the two groups.

RESULTS: After treatment, interleukin-6 (IL-6), IL-8, tumor necrosis factor α (TNF-α), C reactive protein (CRP), serum amylase, urine amylase, and WBC decreased significantly in the two groups, and the decrease was more significant in the observation group. Times to body temperature recovery, vomiting disappearance, abdominal distention disappearance, abdominal pain disappearance, gastrointestinal function recovery, biochemical index recovery, and pancreatic edema disappearance in the observation group were significantly shorter than those of the control group. Hospitalization time in the observation group was significantly less than that of the control group. Total effective rate in observation group was significantly higher than that of the control group (P < 0.01). There was no significant difference in complications between the two groups (P > 0.05).

CONCLUSION: Anisodamine combined with Xuebijing in patients with severe pancreatitis can significantly reduce the levels of inflammatory factors, improve clinical symptoms, and shorten treatment time with high security.

Correlation between expression of 1 α -hydroxylase and hypocalcaemia in rats with severe pancreatitis

OBJECTIVE

To investigate the essential biochemical indices like 1 -hydroxylase and hypocalcaemia in the rats with severe acute pancreatitis and explore the correlation between them.

METHODS

A total of 120 SPF grade Wistar male rats which were in similar physiological status were selected and randomly divided into two groups: sham group (SO group) and severe acute pancreatitis group (SAP group). Then they were divided into 1 h, 3 h, 6 h, and 12 h subgroups according to the killing time. The severe acute pancreatitis model was established by retrograde injection of 5% sodium taurocholate. Serum calcium, serum creatinine, serum urea nitrogen and serum amylase were measured at different time. Serum 1, 25 dihydroxy vitamin D3 level was determined by enzyme linked immunosorbentassay. The expression of 1-hydroxylase protein in the kidney tissue was determined with Western blotting and immunohistochemistry to observe its location. The pathologic features of the kidney tissue section was observed under light microscope and submicroscopic structure of the proximal convoluted tubule epithelial cell was observed under transmission electron microscope.

RESULTS

Compared with the SO group, rats in the SAP group showed continuous pathological injury as time went by. There was significant increase in serum creatinine, serum urea nitrogen and serum amylase in SAP group compared with the SO group 1, 3, 6, 12 hours after the operation (P<0.05). There was significant decrease in serum calcium and 1, 25 dihydroxy vitamin D3 3, 6, 12 hours after the operation (P<0.05). It also showed that the expression of the 1-hydroxylase protein in kidney tissues was upregulated at 1 h, 3 h and decreased at 6 h, 12 h compared with the SO group. The serum calcium, 1, 25 dihydroxy vitamin D3 and the expression of the 1-hydroxylase protein in kidney tissues of the SAP group showed sustaining decrease. Western blotting showed positive correlation between the 1-hydroxylase expression and serum calcium at 3 h, 6 h and 12 h (r=0.976, P<0.001; r=0.948, P<0.001; r=0.742, P=0.001) and also positive correlation between the 1-hydroxylase expression and serum 1, 25 dihydroxy vitamin D3 at 1 h, 3 h, 6 h and 12 h (r=0.935, P<0.001; r=0.952, P<0.001; r=0.917, P<0.001; r=0.874, P<0.001).

CONCLUSIONS

At the early stage of the kidney injury, the expression of 1-hydroxylase in the kidney tissue is reduced with the progress of the disease and the decrease in its activity has a correlation with the hypocalcaemia.

Inflammatory profiling of early experimental necrotizing pancreatitis. Life Sci. 2015;126:76-80. [PMID: 25711429 DOI: 10.1016/j.lfs.2015.01.029]

AIMS

Inflammatory mediators play a pivotal role in severe necrotizing pancreatitis (SNP). Therapeutic approaches aim at the early inflammatory liberation of cytokines to avoid systemic complications. The present study evaluates the kinetics of inflammatory mediator release in SNP.

MAIN METHODS

Experimental SNP was induced in male Wistar rats using the GDOC model. The animals were allocated into seven groups (n = 6/group). In group 1, sample harvesting was performed after sham operation while in groups 2-7 this was performed 1 h, 2 h, 4 h, 6 h, 9 h, and 12 h after initiation of SNP, respectively. Inflammatory mediator release,morphologic injury, and tissue MPO concentrations were evaluated between 1 and 12 h after induction.

KEY FINDINGS

Pancreatic injury showed a continuous increase over the observation period (p b 0.05, respectively). MPO levels in the pancreas and lungs increased until 12 h after induction (p b 0.05, respectively). Antiinflammatory IL-10 showed an early peak and the pro-inflammatory mediators TNFα and IL-1β peaked after 6 and 9 h, respectively (p b 0.05, respectively). HMGB1 levels constantly increased over time (p b 0.05, respectively).

SIGNIFICANCE

The present study shows the release of relevant pro- and anti-inflammatory mediators in SNP for the first time in one single experimental setup. Inflammatory mediators peak within the first few hours after SNP induction. Consequently, the effect of therapeutic approaches on early changes in cytokine release should be evaluated later than 2 h after initiation.

Relationship between development and progression of severe acute pancreatitis and neutrophil apoptosis-related proteins in rats

AIM: To investigate the relationship between the development and progression of severe acute pancreatitis (SAP) and apoptosis-related proteins in rats.

METHODS: Sixty SD rats were randomly divided into two groups: acute necrotizing pancreatitis (ANP) group and sham-operated (SO) group (n = 30 for each). At 3, 6, and 12 h after induction of ANP, the rats were sacrificed and blood samples were collected from the inferior vena cava. Density gradient centrifugation was conducted to separate polymorpho nuclear neutrophils (PMNs), and PMN apoptosis was determined by flow cytometry. PMNs collected at 12 h were lysed, and label-free technology was used to identify apoptosis-related proteins. Twenty-eight SAP patients treated at our hospital from June 2008 to June 2012 were randomly divided into a treatment group and a control group (n = 14 for each). The control group underwent conventional treatment, while the treatment group was treated with conventional treatment plus continuous infusion of somatostatin. The mean duration of abdominal pain, amylase recovery time, length of hospital stay, and the incidence of complications, rate of conversion to surgery, and mortality were compared between the two groups.

RESULTS: PMN apoptosis was significantly delayed in the ANP group compared to the SO group at all time points (all P < 0.01). Four PMN apoptosis-related proteins were identified: 78 KDa glucose-regulated protein, RhoGTPase, L-lactic acid dehydrogenase A chain, and hemoglobin α2 chain (ANP/SO ratios: 1.953614, 3.526625, 1.766764, 0.609825; all P < 0.05). The mean duration of abdominal pain, amylase recovery time and length of stay were significantly shorter (P = 0.041, 0.001, 0.000), and the incidence of complications, rate of conversion to surgery, and mortality were significantly lower in the treatment group than in the control group (P = 0.022, 0.029, 0.029).

CONCLUSION: PMN apoptosis delay in ANP may be mediated by apoptosis-related proteins. Somatostatin therapy can significantly shorten the duration of patient's clinical symptoms and reduce complications and mortality.

Walled-off pancreatic necrosis: Wishing our pancreatitis nomenclature was correct

The ultimate reason why pancreatologists have strived to establish definitions for inflammatory pathologies of the pancreas is to improve patient care. Although the Atlanta Classification has been used for around for 17 years, considerable misunderstanding of the key elements of the nomenclature still persists. While a recent article by Stamatakos et al aimed to deal with an entity not clearly defined in the 1993 document, it is replete with factual and conceptual errors as well as contradictory statements.

Walled-off pancreatic necrosis

Walled-off pancreatic necrosis (WOPN), formerly known as pancreatic abscess is a late complication of acute pancreatitis. It can be lethal, even though it is rare. This critical review provides an overview of the continually expanding knowledge about WOPN, by review of current data from references identified in Medline and PubMed, to September 2009, using key words, such as WOPN, infected pseudocyst, severe pancreatitis, pancreatic abscess, acute necrotizing pancreatitis (ANP), pancreas, inflammation and alcoholism. WOPN comprises a later and local complication of ANP, occurring more than 4 wk after the initial attack, usually following development of pseudocysts and other pancreatic fluid collections. The mortality rate associated with WOPN is generally less than that of infected pancreatic necrosis. Surgical intervention had been the mainstay of treatment for infected peripancreatic fluid collection and abscesses for decades. Increasingly, percutaneous catheter drainage and endoscopic retrograde cholangiopancreatography have been used, and encouraging results have recently been reported in the medical literature, rendering these techniques invaluable in the treatment of WOPN. Applying the recommended therapeutic strategy, which comprises early treatment with antibiotics combined with restricted surgical intervention, fewer patients with ANP undergo surgery and interventions are ideally performed later in the course of the disease, when necrosis has become well demarcated.