Simplified admission criterion for predicting severe complications of gallstone pancreatitis

Ameliorative effect of certolizumab on experimentally induced acute necrotic pancreatitis in rats

OBJECTIVE

The effects of Certolizumab, a pegylated monoclonal antibody to tumor necrosis factor α, on experimentally induced acute pancreatitis (AP) were examined.

METHODS

Thirty-six Wistar Albino male rats were randomly divided into four groups. Group I was the control group and no medication administered to this group. Group II was the Certolizumab group, and 100 ml/kg serum physiologic administered into the biliopancreatic duct and a single dose of 10 μg Certolizumab was simultaneously administered intraperitoneally. Acute pancreatitis was induced with a retrograde injection of 3% Na taurocholate into the common biliopancreatic duct in the study (Group III) and treatment (Groups IV) groups. Rats were sacrificed 72 hours later. Serum amylase, lipase, lactate dehydrogenase activities, along with pancreatic histopathology, were examined.

RESULTS

Certolizumab treatment significantly decreased serum amylase, lipase, and LDH levels; histopathologically edema, hemorrhage, parenchymal necrosis, fat necrosis, and infiltration scores; immunohistochemically MDA, MPO, TNF-α and Caspase-3 activity.

CONCLUSION

The results support the idea that certolizumab might be beneficial for the severity of AP.

Risk Factors of Hyperglycemia in Patients After a First Episode of Acute Pancreatitis: A Retrospective Cohort

OBJECTIVES

The aim of this study was to evaluate the risk factors for hyperglycemia development after a first episode of acute pancreatitis (AP).

METHODS

Three hundred and ten patients treated for AP were retrospectively evaluated. Hyperglycemia was determined by fasting blood glucose. All data were collected from the medical records room database and a follow-up telephone call.

RESULTS

The incidence rate of hyperglycemia was obviously increased 5 years after the event. Hazard ratios (HRs) of developing hyperglycemia in patients with hyperlipidemia, fatty liver, and hypertension were 2.52 (P < 0.001), 1.87 (P = 0.01), and 1.78 (P = 0.017), respectively. Patients of biliary origin that underwent endoscopic retrograde cholangiopancreatography presented a 4.62-fold greater risk than those managed conservatively. Other risk factors were random blood glucose greater than 8.33 mmol/L (HR, 4.19; P < 0.001), lactate dehydrogenase greater than 350 U/L (HR, 1.99; P = 0.017), calcium less than 1.75 mmol/L (HR, 3.86; P = 0.004), and elevated creatine kinase (HR, 2.74; P = 0.001). Patients with AB blood type showed 2.92-fold greater risk compared with those with O blood type. Among them, hyperlipidemia and hyperglycemia on admission were the only independent risk factors (both P < 0.05).

CONCLUSIONS

Hyperlipidemia, fatty liver, hypertension, endoscopic retrograde cholangiopancreatography treatment, acute hyperglycemia, elevated lactate dehydrogenase and creatine kinase, decreased calcium, and AB blood type were risk factors for hyperglycemia development after AP.

A prospective study of the Bedside Index for Severity in Acute Pancreatitis (BISAP) score in acute pancreatitis: an Indian perspective

INTRODUCTION

A simple and easily applicable system for stratifying patients with acute pancreatitis is lacking. The aim of our study was to evaluate the ability of BISAP score to predict mortality in acute pancreatitis patients from our institution and to predict which patients are at risk for development of organ failure, persistent organ failure and pancreatic necrosis.

METHODS

All patients with acute pancreatitis were included in the study. BISAP score was calculated within 24 h of admission. A Contrast CT was used to differentiate interstitial from necrotizing pancreatitis within seven days of hospitalization whereas Marshall Scoring System was used to characterize organ failure.

RESULTS

Among 246 patients M:F = 153:93, most common aetiology among men was alcoholism and among women was gallstone disease. 207 patients had no organ failure and remaining 39 developed organ failure. 17 patients had persistent organ failure, 16 of those with BISAP score ≥3. 13 patients in our study died, out of which 12 patients had BISAP score ≥3. We also found that a BISAP score of ≥3 had a sensitivity of 92%, specificity of 76%, a positive predictive value of 17%, and a negative predictive value of 99% for mortality.

DISCUSSION

The BISAP score is a simple and accurate method for the early identification of patients at increased risk for in hospital mortality and morbidity.

Is the end of the T-tube drainage era in laparoscopic choledochotomy for common bile duct stones is coming? A systematic review and meta-analysis

OBJECTIVE

This study aims to compare the efficacy and safety of T-tube free (TTF) versus T-tube drainage (TTD) after laparoscopic common bile duct exploration (LCBDE).

BACKGROUND

LCBDE has been proven to be an effective and preferred treatment approach for uncomplicated choledocholithiasis, and the appropriateness of T-tube placement after laparoscopic choledochotomy for common bile duct (CBD) stones is still under debate.

METHODS

A systematic literature search (PubMed, EMBASE, Science Citation Index, Springer-Link, and Cochrane Central Register of Controlled Trials) was performed. Postoperative complications were evaluated/graded according to the modified Clavien classification. Other variables extracted including primary closures of the CBDs and the associated assistant methods, T-tube types, and placement durations. Stratified and sensitivity analyses were performed both to explore heterogeneity between studies and to assess the effects of the study qualities.

RESULTS

A total of 956 patients from 12 studies were included. The pooled odds ratio for postoperative complications and biliary-specific complications in TTF was found to be 0.59 [95% confidence interval (CI), 0.38-0.91; P = 0.02], 0.62 (95% CI, 0.36-1.06; P = 0.08), respectively, when compared with TTD. Operative time and hospital stay were significantly decreased in the TTF group, with the pooled weighted mean differences being 18.84 minutes (95% CI, -27.01 to 10.67; P < 0.01) and 3.22 days (95% CI, -4.59 to 1.84; P < 0.01), respectively.

CONCLUSIONS

The results of this meta-analysis demonstrate that among patients undergoing laparoscopic choledochotomy for common bile duct stones, primary closure of the CBD alone is superior to TTD; however, there is no significant benefit in terms of primary duct closure with various internal or external drainage techniques. Further randomized controlled trials are eagerly awaited to prove these findings.

A prospective evaluation of the bedside index for severity in acute pancreatitis score in assessing mortality and intermediate markers of severity in acute pancreatitis

OBJECTIVES

Our aim was to prospectively evaluate the ability of the bedside index for severity in acute pancreatitis (BISAP) score to predict mortality as well as intermediate markers of severity in a tertiary center.

METHODS

The BISAP score was evaluated among 397 consecutive cases of acute pancreatitis admitted to our institution between June 2005 and December 2007. BISAP scores were calculated on all cases using data within 24 h of presentation. The ability of the BISAP score to predict mortality was evaluated using trend and discrimination analysis. The optimal cutoff score for mortality from the receiver operating curve was used to evaluate the development of organ failure, persistent organ failure, and pancreatic necrosis.

RESULTS

Among 397 cases, there were 14 (3.5%) deaths. There was a statistically significant trend for increasing mortality (P < 0.0001) with increasing BISAP score. The area under the receiver operating curve for mortality by BISAP score in the prospective cohort was 0.82 (95% confidence interval: 0.70, 0.95), which was similar to that of the previously published validation cohort. A BISAP score >or=3 was associated with an increased risk of developing organ failure (odds ratio=7.4, 95% confidence interval: 2.8, 19.5), persistent organ failure (odds ratio=12.7, 95% confidence interval: 4.7, 33.9), and pancreatic necrosis (odds ratio=3.8, 95% confidence interval: 1.8, 8.5).

CONCLUSIONS

The BISAP score represents a simple way to identify patients at risk of increased mortality and the development of intermediate markers of severity within 24 h of presentation. This risk stratification capability can be utilized to improve clinical care and facilitate enrollment in clinical trials.

Endogenous catecholamine stimulates alveolar fluid clearance in rats with acute pancreatitis

BACKGROUND AND OBJECTIVE

Acute pancreatitis causes pulmonary oedema with the accumulation of fluid in the alveolar spaces, possibly due to reduced clearance. This study tested the hypothesis that acute pancreatitis decreases alveolar fluid clearance in a rat model of pulmonary oedema during acute pancreatitis.

METHODS

Acute pancreatitis was induced by a retrograde injection of 5% taurocholate sodium (0.2 mL) into the common bile duct. The lungs were isolated 4, 24 and 48 h after the induction of acute pancreatitis and alveolar fluid clearance was measured in the absence of pulmonary perfusion.

RESULTS

Alveolar fluid clearance increased to 31.0 +/- 3.5% of instilled volume/h in rats with acute pancreatitis for 4 h compared with 17.3 +/- 1.0% of instilled volume/h in sham rats (P < 0.01), then returned to the control level 48 h after acute pancreatitis (16.0 +/- 4.1% of instilled volume/h). In contrast, the lung water to dry lung weight ratio decreased maximally 24 h after acute pancreatitis (P < 0.01), then returned to the control level 48 h after acute pancreatitis. The plasma epinephrine levels increased to 25-fold higher in rats with acute pancreatitis for 4 h than in sham rats without acute pancreatitis. Prazosin (an alpha(1)-adrenergic antagonist, 10(-4) mol/L), yohimbine (an alpha(2)-adrenergic antagonist, 10(-4) mol/L) or a bilateral adrenalectomy inhibited the increase in part, a combination of prazosin (10(-4) mol/L) and yohimbine (10(-4) mol/L) completely inhibited the increase in alveolar fluid clearance in rats after acute pancreatitis for 4 h, whereas propranolol (a beta-adrenergic antagonist, 10(-4) mol/L) had no effect.

CONCLUSIONS

Endogenous catecholamine stimulates alpha-adrenoceptors and increases alveolar fluid clearance in rats with acute pancreatitis.

Predictors of vascular and gastrointestinal complications in severe acute pancreatitis

AIM

To determine prognostic factors for arterial injury and gastrointestinal perforation in patients with severe acute pancreatitis (AP).

METHODS

A prospective cohort study was performed in 39 patients with AP whose Ranson scores were > or =3. The following parameters were assessed: Ranson score, APACHE II score, C-reactive protein (CRP) concentration on admission and on day 7, and contrast-enhanced computed tomography (CT) scans on admission (first CT) and between days 6 and 8 (second CT). The Balthazar CT severity index was calculated.

RESULTS

Six patients developed seven vascular and/or gastrointestinal complications (duodenal perforations in 3 and arterial pseudoaneurysm in 4). CRP on day 7 and the CT severity indices at the second CT were significantly higher in the complication group than in the noncomplication group. A stepwise logistic regression analysis demonstrated that CRP > or =15 mg/dl on day 7 and CT severity index > or =7 at the second CT were independent risk factors (p = 0.02 and 0.04, respectively). The odds ratio for CRP > or =15 mg/dl was 23.0 and 15.7 for a CT severity index of > or =7.

CONCLUSION

A persistent elevation of the CRP concentration and a high CT severity index are independent risk factors for local complications associated with AP.

Gallstone Pancreatitis: A Benign Disease in Hispanics

Little is known about ethnic differences among patients with gallstone pancreatitis in the United States. The purpose of this study was to compare Hispanic and non-Hispanic patients with gallstone pancreatitis with regard to severity of disease, level of care required, length of hospital stay, and clinical outcomes. A retrospective cohort study of 198 consecutive patients with gallstone pancreatitis was performed from 2003 to 2005. Overall, 161 patients were Hispanic and 37 were non-Hispanic. The average age of Hispanic patients was 41 years versus 47.5 years in the non-Hispanic group ( P = 0.02). Only 16 (10%) Hispanic patients had a Ranson score of 2 or greater versus nine (24%) of the non-Hispanic group ( P = 0.03). Only 39 (24%) Hispanic patients were admitted to an intensive care unit or stepdown unit versus 17 (46%) of the non-Hispanic group ( P = 0.01). Hispanic patients underwent cholecystectomy at an average of 5.8 days after admission versus 6.6 days for non-Hispanic patients ( P = 0.07). There was a 4 per cent complication rate and a 2 per cent readmission rate overall with no statistically significant differences between the two groups and no mortality. The majority of Hispanic patients with gallstone pancreatitis have a benign disease process, presenting at a younger age, with less severe disease that infrequently requires intensive care unit admission.

Admission serum glucose level: an accurate predictor of outcome in gallstone pancreatitis

OBJECTIVES

Early identification of patients at high risk of complications from acute pancreatitis is important; as yet, no simple and accurate method has been identified. The aim was to evaluate admission serum glucose as a prognostic marker in gallstone pancreatitis.

METHODS

Retrospective review of consecutive admissions with gallstone pancreatitis to a large urban hospital was made. Serum glucose levels, Glasgow scores, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were recorded. Outcomes considered were death, intensive care requirement, local complications, and length of hospital stay.

RESULTS

There was a total of 184 admissions (122 women and 62 men; mean age, 55.4 years). Serum glucose of 8.3 mmol/L or higher was as good as APACHE II score of 8 or above (likelihood ratios [LRs] of 2.51 and 2.84, respectively) in predicting mortality (overall probability, 4.3%). Overall, 9.2% of the patients were admitted to intensive care units, and risk was significantly higher in patients with glucose of 8.3 mmol/L or higher (LR, 3.23; P < 0.001) or APACHE II score of 8 or above (LR, 1.9; P < 0.02). Local complications occurred in 12.0% of the patients, and the risk significantly increased in patients with glucose of 8.3 mmol/L or higher (LR, 2.61; P < 0.001) but not for APACHE II or Glasgow scores. Patients with admission serum glucose of 8.3 mmol/L or higher had a mean length of stay of 17.9 days as compared with 7.1 days for patients with admission serum glucose of less than 8.3 mmol/L (P < 0.001).

CONCLUSIONS

In gallstone pancreatitis, an elevated admission serum glucose level offers more prognostic information than Glasgow and APACHE II scores.

O papel da avaliação inicial simplificada no prognóstico da pancreatite aguda

OBJETIVO: Correlacionar a avaliação clínico-laboratorial inicial simplificada com a gravidade da pancreatite aguda e a presença de necrose. MÉTODO: Foi realizado um estudo retrospectivo dos pacientes com diagnóstico final de PA internados no Hospital Universitário Clementino Fraga Filho - UFRJ entre janeiro de 1990 e agosto de 2002. Foi considerado apenas o primeiro episódio de cada paciente. Os dados obtidos foram submetidos a análise estatística. Foram estudados 164 pacientes onde a idade média foi de 43,7 anos. RESULTADOS: A etiologia biliar foi a mais freqüente com 43,9% dos casos. A incidência de necrose foi de 21,3% e a mortalidade global de 23,2%. Observamos que a ausência de taquicardia na admissão estava associada à forma branda da doença, e que os níveis plasmáticos de uréia e creatinina elevados na admissão estão associados à forma grave da doença, e a hiperglicemia (121mg/dl) à necrose pancreática. CONCLUSÕES: A avaliação inicial simplificada ainda tem espaço, embora que limitado, no acompanhamento do paciente com PA.

Cost-effective method for laparoscopic choledochotomy

BACKGROUND

Recent reports have noted that postoperative complications following open or laparoscopic choledochotomy for common bile duct (CBD) exploration are mainly related to the T-tube presence, and that there has been no trend of decrease in the laparoscopic era. Laparoscopic endobiliary stent placement with primary closure of the CBD has been proposed as a safe and effective alternative to T-tube placement.

METHODS

Between January 1999 and January 2003, 53 consecutive patients suffering from proven choledocholithiasis underwent laparoscopic common bile exploration (LCBDE) via choledochotomy. In the early period, a T-tube was placed at the end of the procedure (group A, n = 32) while, from June 2001 onwards, laparoscopic biliary stent placement and primary CBD closure were chosen as the drainage method (group B, n = 21).

RESULTS

Six patients developed T-tube-related complications postoperatively. Univariate analysis revealed statistically significant lower morbidity rate and shorter postoperative hospital stay for the stent group. Although not statistically significant, a median saving of 780 UK pounds per patient was observed in the stent group.

CONCLUSION

Biliary endoprosthesis placement following laparoscopic choledochotomy avoids the well-known complications of a T-tube, leading to a shorter postoperative hospital stay. The method is safe and effective and it should also be considered as cost-effective compared to T-tube placement. Further studies are required in order to document cost-effectiveness of the method.

Advantages of laparoscopic stented choledochorrhaphy over T-tube placement

Background

Postoperative complications after laparoscopic choledochotomy are mainly related to the T tube. Both laparoscopic endobiliary stent placement with primary closure of the common bile duct (CBD) and primary closure of the CBD without drainage have been proposed as safe and effective alternatives to T-tube placement.

Methods

This was a retrospective analysis of data collected prospectively on 53 consecutive patients suffering from proven choledocholithiasis who underwent laparoscopic CBD exploration through a choledochotomy between January 1999 and January 2003. In the early period a T-tube was placed at the end of the procedure (n = 32). Biliary stent placement and primary CBD closure was performed from June 2001 (n = 21).

Results

There were no significant differences in epidemiological characteristics, preoperative factors or intraoperative findings between the groups. Seven patients developed complications, six in the T-tube group and one in the stent group. Univariate analysis revealed a significantly lower morbidity rate and shorter postoperative hospital stay in the stent group.

Conclusion

Placement of a biliary endoprosthesis after laparoscopic choledochotomy achieves biliary decompression, and avoids the complications of a T tube, leading to a shorter postoperative hospital stay. The method is a safe and effective alternative method of CBD drainage after laparoscopic choledochotomy.

A technique for safe placement of a biliary endoprosthesis after laparoscopic choledochotomy

BACKGROUND

Biliary endoprosthesis has been proposed as an alternative to T-tube placement after laparoscopic choledochotomy in an attempt to eliminate the complications associated with T-tubes. Biliary endoprostheses have been, until now, placed under fluoroscopic guidance. We present a modification of Gersin's method for endoprosthesis placement under direct vision.

PATIENTS AND METHODS

As of July 2001, seven patients who fulfilled the criteria for common bile duct (CBD) exploration through a choledochotomy, a biliary endoprosthesis was inserted under direct vision at the end of the procedure with primary closure of the CBD above it. In all cases, plastic biliary stents 10F in diameter were used ranging from 5 to 10 cm in length. We describe in detail the technique of CBD stent placement using the choledochoscope as the advancing device. We also propose the use of intraoperative cholangiography instead of on-table endoscopy to check the final correct position of the stent.

RESULTS

The median postoperative hospital stay was 2 days. Two patients developed transient hyperamylasemia in the immediate postoperative period. None of the patients developed short-term complications (<30 days), namely bile leak, CBD erosion, stent occlusion, or stent migration. The long-term results revealed early return to full daily activities and normal liver function tests. Stents were removed endoscopically 4 weeks after the initial procedure except in two patients who spontaneously passed them.

CONCLUSION

We propose a 10F 10-cm biliary endoprosthesis placed under direct vision as a safe, effective, time-sparing, and cost-effective adjunct to CBD exploration through a choledochotomy. Placement of the endoprosthesis is associated with low morbidity and eliminates the complications related to T-tubes.

The house economist and the eating paradox

An important observation of the experiments of George Collier is that animals normally prefer to maintain their body weight by eating a large number of small meals each day. However, as the effort to obtain access to food increases, the animals adapt by changing to a schedule of eating a small number of large meals each day. A strong implication of this is that there is a hidden cost to eating large meals, and this is the basis of the eating paradox that states that although food is a necessary commodity, the act of ingesting it poses certain metabolic problems for animals. Experiments on cephalic insulin secretion, conditioned insulin secretion and meal feeding are discussed to make the point that the economy demonstrated by rats in Collier's paradigm is dictated in part by predictions of the eating paradox.

Correlation between admission laboratory values, early abdominal computed tomography, and severe complications of gallstone pancreatitis

BACKGROUND

Our previous study demonstrated that Balthazar grade D or E pancreatitis on early abdominal computed tomography (CT) scan correlated with severe complications of gallstone pancreatitis (GP).

OBJECTIVE

To compare the efficacy of individual admission laboratory criteria, multiple criteria scoring systems and CT scan for predicting severe complications of GP.

METHODS

Consecutively admitted patients with GP underwent selective early CT scanning (<72 hours). All patients were prospectively monitored for severe complications.

RESULTS

Of the 66 patients studied, 21 (32%) did not undergo for early CT scanning and underwent cholecystectomy with no complications. Forty-five patients (68%) had an early abdominal CT scan. Of the 12 patients with grade E pancreatitis, 6 (50%) developed severe complications versus only 2 of 33 (6%) with grade A to D pancreatitis (P = 0.002). A significant correlation was found between admission white blood cell count > or =14.5 x 10(9)/L and grade E pancreatitis on early CT scan (P = 0.002). However, admission glucose > or =150 mg/dL was the best predictor of complications (sensitivity 100%, negative predictive value 100%).

CONCLUSION

Although Balthazar grade E on early CT scan correlates with severe complications of GP, admission glucose > or =150 mg/dL has a better sensitivity and negative predictive value, is quicker to use, and is more cost-effective as a prognostic indicator.