Management of biliary acute pancreatitis

Association between neutrophil to high-density lipoprotein cholesterol ratio and disease severity in patients with acute biliary pancreatitis

BACKGROUND

The neutrophil to high-density lipoprotein cholesterol ratio (NHR) is independently associated with the severity of various diseases. However, its association with acute biliary pancreatitis (ABP) remains unknown.

METHODS

This study included 1335 eligible patients diagnosed with ABP from April 2016 to December 2022. Patients were divided into low- and high-NHR level groups using an optimal cut-off value determined utilizing Youden's index. Multivariate logistic regression analysis was used to investigate the correlation between NHR and ABP severity. Multivariate analysis-based limited restricted cubic spline (RCS) method was used to evaluate the nonlinear relationship between NHR and the risk of developing moderate or severe ABP.

RESULTS

In this study, multivariate logistic regression analysis indicated an independent association between NHR and ABP severity (p < .001). The RCS analysis showed a linear correlation between NHR and the risk of developing moderate or severe ABP (P for non-linearity > 0.05), and increased NHR was found to be independently associated with a more severe form of the disease.

CONCLUSIONS

Our study suggests that NHR is a simple and practical independent indicator of disease severity, serving as a potential novel predictor for patients with ABP.

Early versus delayed cholecystectomy in biliary pancreatitis: Experience from a Local Acute Care Surgery Unit in Saudi Arabia

Biliary pancreatitis is a common complication of gallstones. Although most patients experience mild disease, around 20% may develop severe pancreatitis with an increased risk of serious complications during recurrent attacks. The objective of our study is to compare the surgical outcomes and length of stay for early versus delayed cholecystectomy, performed within the same admission, for mild pancreatitis in a Saudi tertiary center with an established Acute Care Surgey Unit. This retrospective cohort study included all patients who underwent cholecystectomy during the index admission for biliary pancreatitis between January 2017 and January 2020. Surgical outcomes and hospital length of stay were collected and analyzed to assess overall outcomes for early and delayed cholecystectomy groups. The early group was defined as surgery performed within 72 hours of presentation. Eighty-six patients were included and allocated to the early and delayed cholecystectomy groups. The median length of hospital stay was significantly shorter in the early cholecystectomy group (4 days, IQR 3-5) compared to the delayed group (7 days, IQR 6-9) (P < .001). There was no significant difference in operative time and postoperative complications. Early cholecystectomy for mild biliary pancreatitis appears safe and feasible and may result in a shorter hospital stay.

External application of mirabilite before surgery can reduce the inflammatory response and accelerate recovery in mild acute biliary pancreatitis

OBJECTIVE

Mild acute biliary pancreatitis (MABP) is one of the most common diseases that require surgical treatment. Previous studies have focused on the timing of laparoscopic cholecystectomy (LC) for MABP. However, the impact of its inflammatory response process on the clinical outcome has been rarely reported. This study aimed to investigate the effect of preoperative external application of mirabilite on the inflammatory response and clinical efficacy in MABP.

METHODS

Medical records of patients undergoing LC due to MABP from November 2017 to June 2022 were retrospectively reviewed. Prior to surgery, the control group received the same baseline treatment measures as the study group. The difference was the addition of external application of mirabilite in the study group.

RESULTS

A total of 75 patients were included in the final analysis: 38 patients in the mirabilite group and 37 patients in the control group. Repeated-measures ANOVA (P < 0.01) showed that the white blood cell count (WBC) on the 3rd day of admission and the WBC and C-reactive protein (CRP) level on the 5th day of admission decreased rapidly and significantly in the mirabilite group, compared with the control group. The mirabilite group had earlier anal exhaust time. The number of patients in the mirabilite group and control group with gallbladder wall ≥ 3 mm before the operation was 16 (42.11%) vs. 24 (64.86%), p = 0.048, respectively; and the number of cases with surgical drain placement was 2 (5.26%) vs. 9 (24.32%), p = 0.020, respectively. The intraoperative modified American Fertility Society (mAFS) score of adhesions was lower in the mirabilite group (1.08 ± 0.59 points) than in the control group (1.92 ± 0.60 points), p = 0.000. The mirabilite group, compared to the control group, p = 0.000, had a short waiting time for surgery (5.68 ± 0.70 days vs. 6.54 ± 0.59 days), short operation time (38.03 ± 5.90 min vs. 48.51 ± 8.37 min), and reduced hospitalization time (8.95 ± 0.96 days vs. 9.84 ± 1.07 days).

CONCLUSION

This study demonstrated that preoperative external application of mirabilite can reduce the inflammatory response, decrease the edema and peribiliary adhesions at the surgical site, and accelerate recovery in MABP.

Current trends in acute pancreatitis: Diagnostic and therapeutic challenges

Acute pancreatitis (AP) is an inflammatory disease of the pancreas, which can progress to severe AP, with a high risk of death. It is one of the most complicated and clinically challenging of all disorders affecting the abdomen. The main causes of AP are gallstone migration and alcohol abuse. Other causes are uncommon, controversial and insufficiently explained. The disease is primarily characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. According to the revised Atlanta classification, severity of the disease is categorized into three levels: Mild, moderately severe and severe, depending upon organ failure and local as well as systemic complications. Various methods have been used for predicting the severity of AP and its outcome, such as clinical evaluation, imaging evaluation and testing of various biochemical markers. However, AP is a very complex disease and despite the fact that there are of several clinical, biochemical and imaging criteria for assessment of severity of AP, it is not an easy task to predict its subsequent course. Therefore, there are existing controversies regarding diagnostic and therapeutic modalities, their effectiveness and complications in the treatment of AP. The main reason being the fact, that the pathophysiologic mechanisms of AP have not been fully elucidated and need to be studied further. In this editorial article, we discuss the efficacy of the existing diagnostic and therapeutic modalities, complications and treatment failure in the management of AP.

Acute Pancreatitis (AP) in Pregnancy and Its Complications From an Anesthesia Perspective: A Case Report

Acute pancreatitis (AP) is a rare event in pregnancy that is characterized by a sudden and severe inflammation of the pancreas. The clinical manifestation of AP during pregnancy is highly variable ranging from a mild form to a severe and potentially life-threatening presentation. We share a case of a 29-year-old female (gravida II, para I) who presented in her 33rd gestational week. The patient complained of upper abdominal pain and nausea. Her previous history revealed that she had four episodes of vomiting (food-containing, non-projectile) at home. Her uterine tone was normal, and her cervix was closed. Her white blood cell count was 13,000/mm3, and her C-reactive protein (CRP) level was 65 mg/L. She underwent an emergency laparotomy due to suspected acute appendicitis; however, no peritonitis was found intraoperatively. Further blood tests showed high levels of triglyceride at 87.5 mmol/L. The electrophoretic pattern of lipoprotein was consistent with type V hyperlipoproteinemia. An abdominal computed tomography (CT) confirmed the diagnosis of acute pancreatitis. During follow-up after one month, the patient showed triglyceride levels at 4.75 mmol/L and cholesterol at 6.07 mmol/L. Acute pancreatitis due to hypertriglyceridemia is a rare finding; nonetheless, it should be considered as a potential etiology in pregnant patients with nonobstructive abdominal pain.

In-Hospital Patient Education Markedly Reduces Alcohol Consumption after Alcohol-Induced Acute Pancreatitis

Although excessive alcohol consumption is by far the most frequent cause of recurrent acute pancreatitis (AP) cases, specific therapy is still not well established to prevent recurrence. Generally, psychological therapy (e.g., brief intervention (BI)) is the cornerstone of cessation programs; however, it is not yet widely used in everyday practice. We conducted a post-hoc analysis of a prospectively collected database. Patients suffering from alcohol-induced AP between 2016 and 2021 received 30 min BI by a physician. Patient-reported alcohol consumption, serum gamma-glutamyl-transferase (GGT) level, and mean corpuscular volume (MCV) of red blood cells were collected on admission and at the 1-month follow-up visit to monitor patients’ drinking habits. Ninety-nine patients with alcohol-induced AP were enrolled in the study (mean age: 50 ± 11, 89% male). A significant decrease was detected both in mean GGT value (294 ± 251 U/L vs. 103 ± 113 U/L, p < 0.001) and in MCV level (93.7 ± 5.3 U/L vs. 92.1 ± 5.1 U/L, p < 0.001) in patients with elevated on-admission GGT levels. Notably, 79% of the patients (78/99) reported alcohol abstinence at the 1-month control visit. Brief intervention is an effective tool to reduce alcohol consumption and to prevent recurrent AP. Longitudinal randomized clinical studies are needed to identify the adequate structure and frequency of BIs in alcohol-induced AP.

Development and Evaluation of a Nomogram to Predict the Eventual Severity of the First Episode of Acute Pancreatitis

OBJECTIVE

The aim of this research was to establish a nomogram for early prediction of the severity of acute pancreatitis (AP).

METHODS

A total of 1860 AP patients from 2013 to 2020 were included in this study. According to the 2012 revised Atlanta classification, patients were divided into nonsevere AP group and severe AP (SAP) group. The baseline characteristics and first laboratory indicators after admission between the 2 groups were analyzed using univariate and multivariate logistic regression analysis in training set. R language was used for establishing a predictive nomogram and further verified in validation set.

RESULTS

Univariate and multivariate logistic regression analysis in the training set showed red blood cell distribution width, d -dimer, apolipoprotein A1, and albumin were independent factors for SAP. A predictive nomogram was accordingly established based on the 4 indicators. Validation on this predictive nomogram showed high internal validation concordance index of 0.940 (95% confidence interval, 0.922-0.958) and high external validation concordance index of 0.943 (95% confidence interval, 0.920-0.966). The calibration curve, receiver operating characteristic curve, and decision curve analysis all showed that the nomogram had good predictive ability.

CONCLUSIONS

This nomogram may be an effective clinical tool for predicting the first episode of SAP.

Progress in research of liver injury induced by acute biliary pancreatitis

Acute biliary pancreatitis (ABP) not only causes acute inflammation of the pancreas, but also leads to obstruction or infection of the biliary system. Liver injury is one of the most common complications of ABP. The pathological mechanisms mainly include infection and endotoxin, cholestasis, pancreatic enzyme damage, microcirculatory disorders, and oxidative stress, and the research conclusions are mostly derived from animal experiments. On the basis of routine medical treatment of ABP, active anti-infective treatment and rapid relief of biliary obstruction can promote the recovery of ABP-related liver injury.

Evaluation and management of acute pancreatitis

Acute pancreatitis (AP) is one of the most common gastrointestinal causes for hospi-talization in the United States. In 2015, AP accounted for approximately 390000 hospitalizations. The burden of AP is only expected to increase over time. Despite recent advances in medicine, pancreatitis continues to be associated with a substantial morbidity and mortality. The most common cause of AP is gallstones, followed closely by alcohol use. The diagnosis of pancreatitis is established with any two of three following criteria: (1) Abdominal pain consistent with that of AP; (2) Serum amylase and/or lipase greater than three times the upper limit of normal; and (3) Characteristics findings seen in cross-sectional abdominal imaging. Multiple criteria and scoring systems have been established for assessing severity of AP. The cornerstones of management include aggressive intravenous hydration, appropriate nutrition and pain management. Endoscopic retrograde cholangiopancreatography and surgery are important aspects in management of acute gallstone pancreatitis. We provide a comprehensive review of evaluation and management of AP.