1
|
Phillips ME, Smith N, McPherson S, O'Reilly DA. Nutritional assessment and management in acute pancreatitis: Ongoing lessons of the NCEPOD report. J Hum Nutr Diet 2021; 35:504-511. [PMID: 34905277 DOI: 10.1111/jhn.12968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/14/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Acute pancreatitis (AP) is a medical emergency that is common, poorly understood and carries a significant risk of death. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) undertook a comprehensive report into the current management of AP in the UK. The study aimed to provide a more detailed analysis of the findings related to nutritional assessment and support. METHODS The data presented here were analysed from the core dataset used in the NCEPOD study. Adult patients admitted between January and June 2014 with a coded diagnosis of AP were included. A clinical and organisational questionnaire was used to collect data and submitted case notes subjected to peer review. Nutritional data, including assessment and provision of support, were analysed. RESULTS One hundred and forty-seven out of 168 (87.5%) hospitals had a nutrition team in place. A screening nutritional assessment was performed in only 67.4% (368/546) of patients. Subsequent referral to a dietitian and nutrition team input occurred in 39% (201/521) and 25% (143/572) of patients, respectively. Supplemental nutrition was considered and used in 240/555 (43.2%) patients. Overall management of the patients' nutrition was considered adequate by the case reviewers in only 281/332 (85%) of cases and by the clinicians in 77% (421/555) of cases. CONCLUSIONS Many patients do not receive adequate nutritional assessment and, in up to 23% of cases, nutritional intervention is not adequate. Pancreatic exocrine insufficiency is likely under recognised and undertreated. Nutritional strategies to support early intervention and to support clinicians outside of tertiary pancreatic centres are warranted.
Collapse
Affiliation(s)
- Mary E Phillips
- Department of Nutrition and Dietetics, Royal Surrey County Hospital, Guildford, UK.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Neil Smith
- National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK
| | - Simon McPherson
- National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK.,Department of Interventional Radiology, Leeds General Infirmary, Leeds, UK
| | - Derek A O'Reilly
- National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK.,Department of Surgery, Manchester Royal Infirmary, Manchester, UK
| |
Collapse
|
2
|
Liu ZW, Yang SZ, Wang PF, Feng J, He L, Du JD, Xiao YY, Jiao HB, Zhou FH, Song Q, Zhou MT, Xin XL, Chen JY, Ren WZ, Lu SC, Cai SW, Dong JH. Minimal-access retroperitoneal pancreatic necrosectomy for infected necrotizing pancreatitis: a multicentre study of a step-up approach. Br J Surg 2020; 107:1344-1353. [PMID: 32449154 DOI: 10.1002/bjs.11619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/23/2019] [Accepted: 03/16/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Various minimally invasive approaches have been described for infected necrotizing pancreatitis. This article describes a modified minimal-access retroperitoneal pancreatic necrosectomy (MARPN) procedure assisted by gas insufflation. METHODS This retrospective, observational study documented patients who had undergone a step-up MARPN between 1 January 2010 and 31 December 2016. A minimum follow-up of 1 year was required for inclusion. The step-up approach involved percutaneous catheter drainage followed by the modified MARPN and necrosectomy. If more than one access site was needed it was categorized as complex MARPN. RESULTS Of 212 patients with infected necrotizing pancreatitis, 164 (77·4 per cent) underwent a step-up approach. The median number of percutaneous catheter drains and MARPN procedures was 3 (range 1-7) and 1 (1-6) respectively. Ninety patients (54·9 per cent) underwent complex MARPN. For residual necrosis after MARPN, three patients (1·8 per cent) underwent sinus tract gastroscopy, and 11 (6·7 per cent) had sinography combined with a tube change. However, operations in 13 patients (7·9 per cent) required conversion to open surgery. Postoperative complications developed in 103 patients (62·8 per cent). The mortality rate was 6·1 per cent (10 deaths). CONCLUSION A step-up approach using a modified MARPN for infected necrotizing pancreatitis is a reasonable option.
Collapse
Affiliation(s)
- Z-W Liu
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - S-Z Yang
- Centre of Hepato-pancreato-biliary Diseases, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - P-F Wang
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J Feng
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - L He
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J-D Du
- Department of Hepato-pancreato-biliary Surgery, First Affiliated Hospital of Chinese PLA General Hospital, Beijing, China
| | - Y-Y Xiao
- Department of Radiology, Beijing, China
| | - H-B Jiao
- Department of Hepato-pancreato-biliary Surgery, First Affiliated Hospital of Chinese PLA General Hospital, Beijing, China
| | - F-H Zhou
- Critical Care Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Q Song
- Critical Care Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - M-T Zhou
- Pancreatitis Centre, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - X-L Xin
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J-Y Chen
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - W-Z Ren
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - S-C Lu
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - S-W Cai
- Department of Hepato-pancreato-biliary Surgery, Beijing, China
| | - J-H Dong
- Centre of Hepato-pancreato-biliary Diseases, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| |
Collapse
|
3
|
Abstract
Multidisciplinary collaboration (MDC) has been widely adopted in healthcare to optimize patient care. MDC brings several specialized healthcare providers to the table using several methods, including multidisciplinary meetings (MDMs), multidisciplinary clinics, teleconferences, and online multidisciplinary expert panels, to reach the goal of achieving the best diagnosis and treatment plan for complex diseases. Diagnosis and management of acute/chronic pancreatitis is complex which necessitates the development and utilization of MDC. The key members of pancreatitis MDM include gastroenterologists, radiologists, pathologists, hepatobiliary surgeons, chairperson, and a coordinator. After selection of admitted or referred patients, the availability of required information is reviewed, and then each case is discussed. The final diagnosis and treatment plan is confirmed by consensus, especially for complex cases that require endoscopic intervention or pancreatectomy and patients with the possibility of pancreatic adenocarcinoma. It has been shown that MDMs have improved the clinical outcome of patients with acute/chronic pancreatitis. In addition to MDM, the feasibility of multidisciplinary clinics, teleconferences, and online multidisciplinary expert panels for the management of pancreatic disorders has been investigated. Understanding structure, potential advantages, and limitations of MDC will help clinicians and healthcare systems in developing an optimized MDC to improve the management of acute/chronic pancreatitis. This narrative review summarized prior recommendations and explored the impact of MDC on clinical outcomes of patients with pancreatitis. Our recommendations offer a generalizable method that can be utilized by healthcare systems.
Collapse
|
4
|
Elevated triglycerides level in hospital stay as a risk factor of mortality in patients with severe acute pancreatitis. PLoS One 2018; 13:e0207875. [PMID: 30496237 PMCID: PMC6264831 DOI: 10.1371/journal.pone.0207875] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 11/06/2018] [Indexed: 02/05/2023] Open
Abstract
Hypertriglyceridaemia is one of the most common causes of severe acute pancreatitis (SAP). However, the association between elevated triglycerides (TG) level in hospital stay and outcome in SAP patients with normal TG level at admission has not been clearly demonstrated. This retrospective study assessed the serum TG levels of patients with SAP admitted to the intensive care unit (ICU) in 2017. Variables with a statistically significant association with the incidence of in-hospital TG elevation, as determined by univariate analysis, were analysed using a logistic regression model to predictors. Of the 99 patients included in the study, TG levels were within the normal range in 59 (59.59%) patients at admission. Among patients with normal TG level when admitted to ICU, 28 (47.46%) experienced at least one episode of TG level elevation during their ICU stay. Elevated TG level in hospitalization is associated with an increased length of ICU stay, as well as increased mortality. In addition to other factors, propofol usage was independently associated with the occurrence of in-hospital-TG elevation. To conclude, we retrospectively investigated the incidence, outcome, and risk factors for in-hospital TG elevation events in SAP patients admitted to the ICU. We found a high incidence of both preexisting and in-hospital-acquired TG elevation in SAP patients admitted to the ICU. The TG elevation that occurred during the ICU stay was associated with worse outcomes and long-term hospitalization of the ICU. Propofol usage was independently associated with the TG elevation occurrence in the ICU.
Collapse
|
5
|
Barrie J, Jamdar S, Smith N, McPherson SJ, Siriwardena AK, O'Reilly DA. Mis-use of antibiotics in acute pancreatitis: Insights from the United Kingdom's National Confidential Enquiry into patient outcome and death (NCEPOD) survey of acute pancreatitis. Pancreatology 2018; 18:721-726. [PMID: 30075909 DOI: 10.1016/j.pan.2018.05.485] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/21/2018] [Accepted: 05/22/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND International guidelines for the management of acute pancreatitis state that antibiotics should only be used to treat infectious complications. Antibiotic prophylaxis is not recommended. The aim of this study was to analyse antibiotic use, and its appropriateness, from a national review of acute pancreatitis. METHODS Data were collected from The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) study into the management of acute pancreatitis. Adult patients admitted to hospitals in England and Wales between January and June 2014 with a coded diagnosis of acute pancreatitis were included. Clinical and organisational questionnaires were used to collect data and these submissions subjected to peer review. Antibiotic use, including indication and duration were analysed. RESULTS 439/712 (62%) patients received antibiotics, with 891 separate prescriptions and 23 clinical indications. A maximum of three courses of antibiotics were prescribed, with 41% (290/712) of patients receiving a second course and 24% (174/712) a third course. For the first antibiotic prescription, the most common indication was "unspecified" (85/439). The most common indication for the second course was sepsis (54/290), "unspecified" was the most common indication for the third course (50/174). In 72/374 (19.38%) the indication was deemed inappropriate by the clinicians and in 72/393 (18.3%) by case reviewers. CONCLUSIONS Inappropriate use of antibiotics in acute pancreatitis is common. Healthcare providers should ensure that antimicrobial policies are in place as part of an antimicrobial stewardship process. This should include specific guidance on their use and these policies must be accessible, adherence audited and frequently reviewed.
Collapse
Affiliation(s)
- Jenifer Barrie
- Regional Hepato-pancreato-biliary Unit, Manchester Royal Infirmary, Manchester, UK
| | - Saurabh Jamdar
- Regional Hepato-pancreato-biliary Unit, Manchester Royal Infirmary, Manchester, UK
| | - Neil Smith
- National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK
| | - Simon J McPherson
- National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK
| | - Ajith K Siriwardena
- Regional Hepato-pancreato-biliary Unit, Manchester Royal Infirmary, Manchester, UK; Faculty of Medicine, University of Manchester, Manchester, UK
| | - Derek A O'Reilly
- Regional Hepato-pancreato-biliary Unit, Manchester Royal Infirmary, Manchester, UK; Faculty of Medicine, University of Manchester, Manchester, UK. derek.o'
| |
Collapse
|