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Racketa S, Gandhi K, Lambie M. Meropenem versus piperacillin-tazobactam for the treatment of pancreatic necrosis. Diagn Microbiol Infect Dis 2024; 109:116209. [PMID: 38458097 DOI: 10.1016/j.diagmicrobio.2024.116209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 03/10/2024]
Abstract
PURPOSE To date, there are three published guidelines discussing management of infected pancreatic necrosis (IPN) with conflicting recommendations. Specifically, The World Society of Emergency Surgery lists piperacillin-tazobactam as a treatment option in addition to meropenem and ciprofloxacin plus metronidazole. Piperacillin-tazobactam may serve as an effective carbapenem-sparing alternative. Although previous studies shed light on antimicrobial penetration data, there is a lack of clinical data comparing piperacillin-tazobactam to meropenem. The purpose of this study is to compare the efficacy of meropenem and piperacillin-tazobactam for the treatment of IPN. METHODS This was a multicenter, retrospective cohort study conducted across three institutions. Patients with IPN who received either meropenem or piperacillin-tazobactam from January 2015 to December 2020 were included. The primary composite outcome was the incidence of 90-day clinical failure, which encompassed 90-day all-cause mortality and 90-day intra-abdominal infection recurrence. Secondary outcomes included length of hospital stay, antimicrobial duration of therapy, and the need for surgical intervention. RESULTS We identified 229 patients with IPN that received either meropenem or piperacillin-tazobactam during hospital admission. After screening, 63 patients were included in the study. Incidence of 90-day clinical failure was observed in 33 % of the meropenem group and 50 % in the piperacillin-tazobactam group (OR, 1.98; 95 % CI 0.57 to 7.01, p = 0.259). The meropenem group had a lower incidence of 90-day infection recurrence in the piperacillin-tazobactam group (56 % vs 29 %, p = 0.047). CONCLUSIONS Piperacillin-tazobactam may be an efficacious carbapenem-sparing treatment alternative for infected pancreatic necrosis.
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Affiliation(s)
- Savannah Racketa
- AdventHealth Daytona Beach, Department of Pharmacy, 301 Memorial Medical Pkwy., Daytona Beach, FL 32117, USA.
| | - Kelvin Gandhi
- AdventHealth Daytona Beach, Department of Pharmacy, 301 Memorial Medical Pkwy., Daytona Beach, FL 32117, USA
| | - Matthew Lambie
- AdventHealth Daytona Beach, Department of Pharmacy, 301 Memorial Medical Pkwy., Daytona Beach, FL 32117, USA
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2
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Kherabi Y, Michoud C, Villageois-Tran K, Bert F, Pioche M, Lefort A, Lévy P, Rebours V, Zarrouk V. Epidemiology, treatment and outcomes of infected pancreatic necrosis in France: a bicenter study. Infect Dis Now 2024; 54:104866. [PMID: 38367772 DOI: 10.1016/j.idnow.2024.104866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 02/19/2024]
Abstract
INTRODUCTION Acute necrotizing pancreatitis (ANP) mortality increases when pancreatic necrosis is infected (IPN). Current treatment of IPN relies on prolonged antibiotic therapies associated with a step-up strategy of drainage. The objective of this study was to analyze IPN treatment outcomes in two referral centers in France. METHODS Data of consecutive patients with documented IPN hospitalized in two expert centers in France between 2014 and 2019 were retrospectively reviewed. The composite primary outcome was the proportion of unsuccessful management outcome, defined as new emergency drainage to treat sepsis with organ failure, an unplanned new antibiotic course, an unplanned prolongation of antibiotic course and/or death by septic shock, within three months following the diagnosis of ANP. RESULTS All in all, 187 patients (138 males; 74.0%), with documented IPN were included. The most frequently identified microorganism was Escherichia coli (26.2%). Ninety-eight patients (52.4%) were admitted to an intensive care unit or resuscitation ward within the first two days of ANP care. Overall, 126 patients (67.4%) endured an unsuccessful outcome: new emergency drainage to treat acute sepsis (62.0%), unplanned new antibiotic course (47.1%), unplanned prolongation of antibiotic course (44.9%) and/or death by septic shock complicating IPN (8.0%). CONCLUSION The unfavorable evolution in two thirds of patients shows that determination of optimal drainage timing and choice of antibiotic therapy remain major challenges in 2024.
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Affiliation(s)
- Yousra Kherabi
- Internal Medicine Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France.
| | - Claire Michoud
- Gastroenterology Department, Hospices Civils de Lyon, Hôpital Edouard Herriot, Université Claude Bernard Lyon 1, France
| | - Khanh Villageois-Tran
- Microbiology Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France
| | - Frédéric Bert
- Microbiology Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France
| | - Mathieu Pioche
- Gastroenterology Department, Hospices Civils de Lyon, Hôpital Edouard Herriot, Université Claude Bernard Lyon 1, France
| | - Agnès Lefort
- Internal Medicine Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France
| | - Philippe Lévy
- Pancreatology Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France
| | - Vinciane Rebours
- Pancreatology Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France
| | - Virginie Zarrouk
- Internal Medicine Department, AP-HP.Nord, Hôpital Beaujon, Université Paris Cité, Clichy, France
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Sivakumar SG, Sekaran M, Muthukrishnan S, Natesan AV, Nalankilli VP, Senthilnathan P, Palanivelu C. Laparoscopic necrosectomy for acute necrotising pancreatitis: Retrospective analysis of a decade-long experience from a tertiary centre. J Minim Access Surg 2024; 20:127-135. [PMID: 38557646 PMCID: PMC11095801 DOI: 10.4103/jmas.jmas_215_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/01/2023] [Accepted: 12/02/2023] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION The objective of this study is to evaluate the role of minimally invasive surgery for the management of necrotising pancreatitis in acute settings and to propose tailor-made approaches to deal with various locations of pancreatic necrosis. PATIENTS AND METHODS Three hundred and thirteen patients underwent laparoscopic management of necrotising pancreatitis in this study period from January 2010 to June 2021, out of which 122 patients underwent minimally invasive necrosectomy for acute necrotising pancreatitis. The remaining 191 patients underwent laparoscopic internal drainage in the form of cystogastrostomy/cystojejunostomy for walled-off pancreatic necrosis. RESULTS Mean body mass index was 26.45 ± 3.78 kg/sqm. Mean operating time was 56.40 ± 20.48 min and mean blood loss was 120 ± 31.45 mL. Ten patients required reoperation (6 underwent open procedure and 4 underwent laparoscopic redo necrosectomy). Six patients died of multi-organ failure. The mean duration of return of bowel function was 5 ± 1.8 days. The mean length of hospital stay after surgery was 10.19 ± 7.09 days. There were no major wound-related complications. CONCLUSION A minimally invasive approach to pancreatic necrosectomy is safe and feasible with good outcomes in centres with advanced laparoscopic expertise. It requires not only careful case selection but also proper timing and the ideal route of access to achieve optimal outcomes.
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Affiliation(s)
| | - Monika Sekaran
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - Srinivasan Muthukrishnan
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - Anand Vijai Natesan
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - V. P. Nalankilli
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - Palanisamy Senthilnathan
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
| | - Chinnusamy Palanivelu
- Department of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, Chennai, Tamil Nadu, India
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4
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Mathai MJ, Reddy M VS, Shetty V. Analysis of the Accuracy of the Modified CT Severity Index in Predicting Clinical Outcomes in Acute Pancreatitis: A Cross-Sectional Study. Cureus 2024; 16:e56123. [PMID: 38618334 PMCID: PMC11015064 DOI: 10.7759/cureus.56123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 04/16/2024] Open
Abstract
OBJECTIVE To evaluate the accuracy of the modified CT severity index (MCTSI) in predicting the severity of acute pancreatitis and to prognosticate the clinical outcomes. METHODS AND MATERIALS The study was conducted at a tertiary health center between January 2021 and June 2023. A total of 150 consecutive patients with clinical/laboratory features suggestive of acute pancreatitis were included in the study and underwent a contrast-enhanced CT scan within 24 hours of admission. Based on their MCTSI score, these patients had conservative or surgical/endoscopic treatment. Clinical outcomes were assessed in terms of recovery, development of complications, or death. The receiver operating characteristic curve and descriptive statistics were computed to determine the sensitivity and specificity. The data were analyzed using SPSS version 16 software (SPSS Inc., Chicago, IL), and an attempt was made to evaluate the accuracy of MCTSI in predicting these clinical outcomes. RESULTS The mean age of patients in our study was 49.21 ± 11.02 years. Out of the 150 included patients, 103 were men and 47 were women. Compared to 11.68% of severe acute pancreatitis patients who died, 88.32% recovered. The area under the curve was determined as 0.865, based on which the MCTSI score predicted acute pancreatitis clinical outcome with 64% sensitivity and 92% specificity. The MCTSI demonstrated value in predicting clinical outcomes with a p-value of 0.043 ± 0.012 (p < 0.05) in the recovered patients while p = 0.032 ± 0.012 for patients who succumbed. The p-value for MCTSI in predicting complications was p = 0.0012 ± 0.0008 (p < 0.05). CONCLUSION Our study was able to demonstrate the high level of accuracy of the MCTSI score in predicting complications and clinical outcomes, especially in patients with severe acute pancreatitis. The MCTSI serves as a valuable asset in the preliminary evaluation of acute pancreatitis, thereby facilitating appropriate management.
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Affiliation(s)
- Mathew John Mathai
- Department of General Surgery, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Vijay Sai Reddy M
- Department of General Surgery, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Varun Shetty
- Department of General Surgery, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
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Tenner S, Vege SS, Sheth SG, Sauer B, Yang A, Conwell DL, Yadlapati RH, Gardner TB. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol 2024; 119:419-437. [PMID: 38857482 DOI: 10.14309/ajg.0000000000002645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 12/08/2023] [Indexed: 06/12/2024]
Abstract
Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.
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Affiliation(s)
- Scott Tenner
- State University of New York, Health Sciences Center, Brooklyn, New York, USA
| | | | - Sunil G Sheth
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Bryan Sauer
- University of Virginia, Charlottesville, Virginia, USA
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Willis J, vanSonnenberg E. Updated Review of Radiologic Imaging and Intervention for Acute Pancreatitis and Its Complications. J Intensive Care Med 2024:8850666241234596. [PMID: 38414385 DOI: 10.1177/08850666241234596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
This is a current update on radiologic imaging and intervention of acute pancreatitis and its complications. In this review, we define the various complications of acute pancreatitis, discuss the imaging findings, as well as the timing of when these complications occur. The various classification and scoring systems of acute pancreatitis are summarized. Advantages and disadvantages of the 3 primary radiologic imaging modalities are compared. We then discuss radiologic interventions for acute pancreatitis. These include diagnostic aspiration as well as percutaneous catheter drainage of fluid collections, abscesses, pseudocysts, and necrosis. Recommendations for when these interventions should be considered, as well as situations in which they are contraindicated are discussed. Fortunately, acute pancreatitis usually is mild; however, serious complications occur in 20%, and admission of patients to the intensive care unit (ICU) occurs in over 10%. In this paper, we will focus on the imaging and interventional radiologic aspects for the serious complications and patients admitted to the ICU.
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Affiliation(s)
- Joshua Willis
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
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Timmermann L, Schönauer S, Hillebrandt KH, Felsenstein M, Pratschke J, Malinka T, Jürgensen C. Endoscopic and surgical treatment of necrotizing pancreatitis-a comparison of short- and long-term outcome. Langenbecks Arch Surg 2024; 409:58. [PMID: 38347181 PMCID: PMC10861384 DOI: 10.1007/s00423-024-03244-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/29/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND Acute necrotizing pancreatitis is still related to high morbidity and mortality rates. Minimal-invasive treatment options, such as endoscopic necrosectomy, may decrease peri-interventional morbidity and mortality. This study aims to compare the initial operative with endoscopic treatment on long-term parameters, such as endocrine and exocrine functionality, as well as mortality and recurrence rates. METHODS We included 114 patients, of whom 69 were treated with initial endoscopy and 45 by initial surgery. Both groups were further assessed for peri-interventional and long-term parameters. RESULTS In the post-interventional phase, patients in the group of initial surgical treatment (IST) showed significantly higher rates of renal insufficiency (p < 0.001) and dependency on invasive ventilation (p < 0.001). The in-house mortality was higher in the surgical group, with 22% vs. 10.1% in the group of patients following initial endoscopic treatment (IET; p = 0.077). In long-term follow-up, the overall mortality was 45% for IST and 31.3% for IET (p = 0.156). The overall in-hospital stay and intensive care unit (ICU) stay were significantly shorter after IET (p < 0.001). In long-term follow-up, the prevalence of endocrine insufficiency was 50% after IST and 61.7% after IET (p = 0.281). 57.1% of the patients following IST and 16.4% of the patients following IET had persistent exocrine insufficiency at that point (p = < 0.001). 8.9% of the IET and 27.6% of the IST patients showed recurrence of acute pancreatitis (p = 0.023) in the long-term phase. CONCLUSION In our cohort, an endoscopic step-up approach led to a reduced in-hospital stay and peri-interventional morbidity. The endocrine function appeared comparable in both groups, whereas the exocrine insufficiency seemed to recover in the endoscopic group in the long-term phase. These findings advocate for a preference for endoscopic treatment of acute necrotizing pancreatitis whenever feasible.
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Affiliation(s)
- Lea Timmermann
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
| | - Svenja Schönauer
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Karl Herbert Hillebrandt
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Matthäus Felsenstein
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Malinka
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christian Jürgensen
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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8
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Bang JY, Lakhtakia S, Thakkar S, Buxbaum JL, Waxman I, Sutton B, Memon SF, Singh S, Basha J, Singh A, Navaneethan U, Hawes RH, Wilcox CM, Varadarajulu S. Upfront endoscopic necrosectomy or step-up endoscopic approach for infected necrotising pancreatitis (DESTIN): a single-blinded, multicentre, randomised trial. Lancet Gastroenterol Hepatol 2024; 9:22-33. [PMID: 37980922 DOI: 10.1016/s2468-1253(23)00331-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Although the preferred management approach for patients with infected necrotising pancreatitis is endoscopic transluminal stenting followed by endoscopic necrosectomy as step-up treatment if there is no clinical improvement, the optimal timing of necrosectomy is unclear. Therefore, we aimed to compare outcomes between performing upfront necrosectomy at the index intervention versus as a step-up measure in patients with infected necrotising pancreatitis. METHODS This single-blinded, multicentre, randomised trial (DESTIN) was done at six tertiary care hospitals (five hospitals in the USA and one hospital in India). We enrolled patients (aged ≥18 years) with confirmed or suspected infected necrotising pancreatitis with a necrosis extent of at least 33% who were amenable to endoscopic ultrasound-guided drainage. By use of computer-generated permuted block randomisation (block size four), eligible patients were randomly assigned (1:1) to receive either upfront endoscopic necrosectomy or endoscopic step-up treatment. Endoscopists were not masked to treatment allocation, but participants, research coordinators, and the statistician were. Lumen-apposing metal stents (20 mm diameter; 10 mm saddle length) were used for drainage in both groups. In the upfront group, direct necrosectomy was performed immediately after stenting in the same treatment session. In the step-up group, direct necrosectomy or additional drainage was done at a subsequent treatment session if there was no clinical improvement (resolution of any criteria of systemic inflammatory response syndrome or sepsis or one or more organ failure and at least a 25% percentage decrease in necrotic collection size) 72 h after stenting. The primary outcome was the number of reinterventions per patient to achieve treatment success from index intervention to 6 months' follow-up, which was defined as symptom relief in conjunction with disease resolution on CT. Reinterventions included any endoscopic or radiological procedures performed for necrosectomy or additional drainage after the index intervention, excluding the follow-up procedure at 4 weeks for stent removal. All endpoints and safety were analysed by intention-to-treat. This study is registered with ClinicalTrials.gov, NCT05043415 and NCT04113499, and recruitment and follow-up have been completed. FINDINGS Between Nov 27, 2019, and Oct 26, 2022, 183 patients were assessed for eligibility and 70 patients (24 [34%] women and 46 [66%] men) were randomly assigned to receive upfront necrosectomy (n=37) or step-up treatment (n=33) and included in the intention-to-treat population. At the time of index intervention, seven (10%) of 70 patients had organ failure and 64 (91%) patients had walled-off necrosis. The median number of reinterventions was significantly lower for upfront necrosectomy (1 [IQR 0 to 1] than for the step-up approach (2 [1 to 4], difference -1 [95% CI -2 to 0]; p=0·0027). Mortality did not differ between groups (zero patients in the upfront necrosectomy group vs two [6%] in the step-up group, difference -6·1 percentage points [95% CI -16·5 to 4·5]; p=0·22), nor did overall disease-related adverse events (12 [32%] patients in the upfront necrosectomy group vs 16 [48%] patients in the step-up group, difference -16·1 percentage points [-37·4 to 7·0]; p=0·17), nor procedure-related adverse events (four [11%] patients in the upfront necrosectomy group vs eight [24%] patients in the step-up group, difference -13·4 percentage points [-30·8 to 5·0]; p=0·14). INTERPRETATION In stabilised patients with infected necrotising pancreatitis and fully encapsulated collections, an approach incorporating upfront necrosectomy at the index intervention rather than as a step-up measure could safely reduce the number of reinterventions required to achieve treatment success. FUNDING None.
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Affiliation(s)
- Ji Young Bang
- Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | | | - Shyam Thakkar
- Division of Gastroenterology and Hepatology, West Virginia University, Morgantown, WV, USA
| | - James L Buxbaum
- Division of Gastroenterology and Hepatology, University of Southern California, Los Angeles, CA, USA
| | - Irving Waxman
- Division of Digestive Diseases and Nutrition, Rush University, Chicago, IL, USA
| | - Bryce Sutton
- Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Sana F Memon
- Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Shailendra Singh
- Division of Gastroenterology and Hepatology, West Virginia University, Morgantown, WV, USA
| | - Jahangeer Basha
- Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Ajay Singh
- Division of Digestive Diseases and Nutrition, Rush University, Chicago, IL, USA
| | | | - Robert H Hawes
- Digestive Health Institute, Orlando Health, Orlando, FL, USA
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9
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Otsuka Y, Hara A, Minaga K, Sekai I, Kurimoto M, Masuta Y, Takada R, Yoshikawa T, Kamata K, Kudo M, Watanabe T. Leucine-rich repeat kinase 2 promotes the development of experimental severe acute pancreatitis. Clin Exp Immunol 2023; 214:182-196. [PMID: 37847786 PMCID: PMC10714192 DOI: 10.1093/cei/uxad106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 08/10/2023] [Accepted: 09/08/2023] [Indexed: 10/19/2023] Open
Abstract
Translocation of gut bacteria into the pancreas promotes the development of severe acute pancreatitis (SAP). Recent clinical studies have also highlighted the association between fungal infections and SAP. The sensing of gut bacteria by pattern recognition receptors promotes the development of SAP via the production of proinflammatory cytokines; however, the mechanism by which gut fungi mediate SAP remains largely unknown. Leucine-rich repeat kinase 2 (LRRK2) is a multifunctional protein that regulates innate immunity against fungi via Dectin-1 activation. Here, we investigated the role of LRRK2 in SAP development and observed that administration of LRRK2 inhibitors attenuated SAP development. The degree of SAP was greater in Lrrk2 transgenic (Tg) mice than in control mice and was accompanied by an increased production of nuclear factor-kappaB-dependent proinflammatory cytokines. Ablation of the fungal mycobiome by anti-fungal drugs inhibited SAP development in Lrrk2 Tg mice, whereas the degree of SAP was comparable in Lrrk2 Tg mice with or without gut sterilization by a broad range of antibiotics. Pancreatic mononuclear cells from Lrrk2 Tg mice produced large amounts of IL-6 and TNF-α upon stimulation with Dectin-1 ligands, and inhibition of the Dectin-1 pathway by a spleen tyrosine kinase inhibitor protected Lrrk2 Tg mice from SAP. These data indicate that LRRK2 activation is involved in the development of SAP through proinflammatory cytokine responses upon fungal exposure.
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Affiliation(s)
- Yasuo Otsuka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Akane Hara
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Kosuke Minaga
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Ikue Sekai
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Masayuki Kurimoto
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Yasuhiro Masuta
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Ryutaro Takada
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Tomoe Yoshikawa
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Ken Kamata
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Tomohiro Watanabe
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
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10
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Fukuda Y, Mori K, Okada H, Tomita H, Suzuki K, Takada C, Kamidani R, Kawasaki Y, Fukuda H, Minamiyama T, Nishio A, Shimada T, Kuroda A, Uchida A, Kitagawa Y, Fukuta T, Miyake T, Yoshida T, Suzuki A, Tetsuka N, Yoshida S, Ogura S. Decreased neutrophil counts prolong inflammation in acute pancreatitis and cause inflammation spillover to distant organs. Pancreatology 2023; 23:911-918. [PMID: 37981522 DOI: 10.1016/j.pan.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/18/2023] [Accepted: 10/26/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND/OBJECTIVE Acute pancreatitis is an aseptic inflammation caused by pathologically activated pancreatic enzymes and inflammatory mediators produced secondarily by neutrophils and other inflammatory cells and is one of the most difficult diseases to treat. This study aimed to investigate the role of neutrophils in pancreatitis by examining tissue dynamics. METHODS We created a model of caerulein-induced pancreatitis in 12-week-old male granulocyte colony-stimulating factor knockout mice (G-CSF-KO) and wild-type littermate control mice (six intraperitoneal injections of caerulein [80 μg/kg body weight] at hourly intervals for 2 days). Mice were sacrificed 0, 3, 6, 12, 24, 36, 48, 72, and 168 h after caerulein administration and examined histologically. RESULTS The survival rate after one week of caerulein administration was 100 % in the control mice, whereas it was significantly lower (10 %) in the G-CSF-KO mice. Histological examination revealed significant hemorrhage and inflammatory cell migration in the G-CSF-KO mice, indicating prolonged inflammation. CONCLUSION Prolonged inflammation was observed in the G-CSF-KO mice. Tissue cleanup by neutrophils during the acute phase of inflammation may influence healing through the chronic phase.
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Affiliation(s)
- Yohei Fukuda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Kosuke Mori
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Japan
| | - Hideshi Okada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan; Center for One Medicine Innovative Translational Research, Gifu University Institute for Advanced Study, Japan.
| | - Hiroyuki Tomita
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Japan; Center for One Medicine Innovative Translational Research, Gifu University Institute for Advanced Study, Japan.
| | - Kodai Suzuki
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Chihiro Takada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Ryo Kamidani
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Yuki Kawasaki
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Hirotsugu Fukuda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Toru Minamiyama
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Ayane Nishio
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Takuto Shimada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Ayumi Kuroda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Akihiro Uchida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Yuichiro Kitagawa
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Tetsuya Fukuta
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Takahito Miyake
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Takahiro Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Japan
| | - Nobuyuki Tetsuka
- Department of Infection Control, Gifu University Graduate School of Medicine, Japan
| | - Shozo Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan; Abuse Prevention Emergency Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
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Lin J, Han C, Dai N, Bi S, Du D, Xia Q. Effectiveness of Chengqi-series decoctions in treating severe acute pancreatitis: A Systematic review and meta-analysis. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2023; 113:154727. [PMID: 36913877 DOI: 10.1016/j.phymed.2023.154727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/31/2023] [Accepted: 02/20/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Evidence suggests that Dachengqi and its modified decoctions are effective for treating abdominal pain, multiple organ dysfunction syndrome (MODS) and inflammation in various disease conditions. We performed a meta-analysis to ascertain the effectiveness of a series of chengqi decoctions in patients with severe acute pancreatitis (SAP). METHODS We searched Pubmed, Embase, Cochrane library, Web of Science, Chinese National Knowledge Infrastructure, Chinese Biomedical Literature, Wanfang database and China Science and Technology Journal Database before August 2022 to identify eligible randomized controlled trials (RCTs). Mortality and MODS were chosen as primary outcomes. Secondary outcomes included time until relief of abdominal pain, APACHE II score, complications, effectiveness, IL-6 and TNF-α levels. The risk ratio (RR) and standardized mean difference (SMD) with a 95% confidence interval (CI) were selected as effect measures. The quality of evidence was independently assessed by two reviewers using Grading of Recommendations Assessment Development and Evaluation (GRADE) system. RESULTS Twenty-three RCTs (n = 1865) were finally included. The results showed that, compared with routine therapies, chengqi-series decoctions (CQSDs) treatment groups were associated with lower mortality rate (RR: 0.41, 95%CI: 0.32 to 0.53, p = 0.992) and incidence of MODS (RR: 0.48, 95%CI: 0.36 to 0.63, p = 0.885). They also reduced remission time of abdominal pain (SMD: -1.66, 95%CI: -1.98 to -1.35, p = 0.000), complications (RR: 0.52, 95%CI: 0.39 to 0.68, p = 0.716), APACHE II score (SMD: -1.04, 95%CI:-1.55 to -0.54, p = 0.003), IL-6 (SMD: -1.5, 95%CI: -2.16 to -0.85, p = 0.000), TNF-α (SMD: -1.18, 95%CI: -1.71 to -0.65, p = 0.000), and improved curative effectiveness (RR:1.22, 95%CI: 1.14 to 1.31, p = 0.757). The certainty of the evidence for these outcomes was low to moderate. CONCLUSION CQSDs seem to be effective therapy for SAP patients with notable reductions in mortality, MODS and abdominal pain, with low quality evidence. Large-scale, multi-center RCTs that are more meticulous are advised in order to produce superior evidence.
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Affiliation(s)
- Juan Lin
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Chenxia Han
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Ning Dai
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100010, China
| | - Siwei Bi
- Department of Burn and Plastic Surgery, West China Hospital, Sichuan University, Chengdu 610000, Sichuan, China
| | - Dan Du
- Advanced Mass Spectrometry Center, Research Core Facility, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China.
| | - Qing Xia
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu 610041, China.
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12
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Yang Y, Zhang Y, Wen S, Cui Y. The optimal timing and intervention to reduce mortality for necrotizing pancreatitis: a systematic review and network meta-analysis. World J Emerg Surg 2023; 18:9. [PMID: 36707836 PMCID: PMC9883927 DOI: 10.1186/s13017-023-00479-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/19/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND A series of randomized controlled trials have investigated the efficacy and safety of different timings of interventions and methods of intervention. However, the optimal treatment strategy is not yet clear. METHODS We searched PubMed, EMBASE, ClinicalTrials.gov and the Cochrane Library until November 30, 2022. A systematic review and Bayesian network meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Trials comparing different treatment strategies for necrotizing pancreatitis were included. This study was registered in the Prospective Register of Systematic Reviews (CRD42022364409) to ensure transparency. RESULTS We analyzed a total of 10 studies involving 570 patients and 8 treatment strategies. Although no statistically significant differences were identified comparing odds ratios, trends were confirmed by the surface under the cumulative ranking (SUCRA) scores. The interventions with a low rate of mortality were delayed surgery (DS), delayed surgical step-up approach (DSU) and delayed endoscopic step-up approach (DEU), while the interventions with a low rate of major complications were DSU, DEU and DS. According to the clustered ranking plot, DSU performed the best overall in reducing mortality and major complications, while DD performed the worst. Analysis of the secondary endpoints confirmed the superiority of DEU and DSU in terms of individual components of major complications (organ failure, pancreatic fistula, bleeding, and visceral organ or enterocutaneous fistula), exocrine insufficiency, endocrine insufficiency and length of stay. Overall, DSU was superior to other interventions. CONCLUSION DSU was the optimal treatment strategy for necrotizing pancreatitis. Drainage alone should be avoided in clinical practice. Any interventions should be postponed for at least 4 weeks if possible. The step-up approach was preferred.
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Affiliation(s)
- Yang Yang
- grid.265021.20000 0000 9792 1228Department of Surgery, Tianjin Medical University, Tianjin, 300070 China ,grid.417036.7Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, 122 Sanwei Road, Nankai District, Tianjin, 300110 China
| | - Yu Zhang
- grid.265021.20000 0000 9792 1228Department of Surgery, Tianjin Medical University, Tianjin, 300070 China ,grid.417036.7Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, 122 Sanwei Road, Nankai District, Tianjin, 300110 China
| | - Shuaiyong Wen
- grid.265021.20000 0000 9792 1228Department of Surgery, Tianjin Medical University, Tianjin, 300070 China ,grid.417036.7Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, 122 Sanwei Road, Nankai District, Tianjin, 300110 China
| | - Yunfeng Cui
- Department of Surgery, Tianjin Medical University, Tianjin, 300070, China. .,Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, 122 Sanwei Road, Nankai District, Tianjin, 300110, China.
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13
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Clinical characteristics and risk factors of organ failure and death in necrotizing pancreatitis. BMC Gastroenterol 2023; 23:19. [PMID: 36658497 PMCID: PMC9850524 DOI: 10.1186/s12876-023-02651-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Organ failure (OF) and death are considered the most significant adverse outcomes in necrotizing pancreatitis (NP). However, there are few NP-related studies describing the clinical traits of OF and aggravated outcomes. PURPOSE An improved insight into the details of OF and death will be helpful to the management of NP. Thus, in our research, we addressed the risk factors of OF and death in NP patients. METHODS We performed a study of 432 NP patients from May 2017 to December 2021. All patients with NP were followed up for 36 months. The primary end-points were risk factors of OF and death in NP patients. The risk factors were evaluated by logistic regression analysis. RESULTS NP patients with OF or death patients were generally older, had a higher APACHE II score, longer hospital stay, longer ICU stay, as well as a higher incidence of severe acute pancreatitis (SAP), shock and pancreatic necrosis. Independent risk factors related to OF included BMI, APACHE II score and SAP (P < 0.05). Age, shock and APACHE II score (P < 0.05) were the most significant factors correlated with the risk of death in NP patients. Notably, increased mortality was linked to the number of failed organs. CONCLUSIONS NP is a potentially fatal disease with a long hospital or ICU stay. Our study indicated that the incidence of OF and death in NP patients was 69.9% and 10.2%, respectively. BMI, SAP, APACHE II score, age and shock are potential risk factors of OF and death in NP patients. Clinicians should focus on these factors for early diagnosis and appropriate therapy.
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14
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Chen D, Zhao B, Wang L, Qiu Y, Mao E, Sheng H, Jing F, Ge W, Bian X, Chen E, He J. Prognostic performance of the NRS2002, NUTRIC, and modified NUTRIC to identify high nutritional risk in severe acute pancreatitis patients. Front Nutr 2023; 10:1101555. [PMID: 36937348 PMCID: PMC10017740 DOI: 10.3389/fnut.2023.1101555] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/14/2023] [Indexed: 03/06/2023] Open
Abstract
Background Acute pancreatitis (AP) is the most common gastrointestinal disease requiring hospital admission. AP patients are categorized as mild, moderately severe, and severe AP (SAP). For SAP patients, malnutrition increases susceptibility to infection and mortality. The Nutritional Risk Screening 2002 (NRS 2002), the Nutrition Risk in Critically Ill (NUTRIC) score and modified Nutrition Risk in Critically Ill (mNUTRIC) are nutritional risk screening tools of critically ill patients and have not been validated in patients with SAP. It is essential to evaluate the prognostic performance of these nutritional risk screening tools. Materials and methods A retrospective study was designed to validate the NRS 2002, NUTRIC, and mNUTRIC when applied to SAP patients. Receiver operating characteristic curves were plotted to investigate the predictive ability of clinical outcomes by comparing areas under the curve (AUC). Appropriate cut-offs were calculated by using Youden's index. Patients were identified as being at high nutritional risk according to the calculated cut-off values. The effects of different scoring systems on mortalities were calculated using the Cox proportional hazards model. Logistic regression was used to assess the association between the energy provision and 28-day mortality. Results From January 2013 to December 2019, 234 SAP patients were included and analyzed. Patients categorized as high nutritional risk by the NRS 2002 (12.6% versus 1.9% for 28-day and 20.5% versus 3.7% for 90-day), NUTRIC (16.2% versus 0.0% for 28-day and 27.0% versus 0.0% for 90-day), and mNUTRIC (16.4% versus 0.0% for 28-day and 26.4% versus 0.8% for 90-day) had significant higher mortality than those categorized as low nutritional risk. The NUTRIC (AUC: 0.861 for 28-day mortality and 0.871 for 90-day mortality, both cut-off value ≥3) and mNUTRIC (AUC: 0.838 for 28-day and 0.828 for 90-day mortality, both cut-off value ≥3) showed better predictive ability of the 28- and 90-day mortality than the NRS 2002 (AUC: 0.706 for 28-day mortality and 0.695 for 90-day mortality, both cut-off value ≥5). Conclusion The NRS 2002, NUTRIC, and mNUTRIC scores were predictors for the 28- and 90-day mortalities. The NUTRIC and mNUTRIC showed better predictive ability compared with the NRS 2002 when applied to SAP patients.
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Affiliation(s)
- Dayu Chen
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Department of Pharmacy, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Bing Zhao
- Emergency Department, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Linyu Wang
- Department of Pharmacy, The Affiliated Cancer Hospital of Guangxi Medical University, Nanning, China
| | - Yusi Qiu
- Department of Pharmacy, Guigang People’s Hospital, Guigang, China
| | - Enqiang Mao
- Emergency Department, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huiqiu Sheng
- Emergency Department, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Jing
- Emergency Department, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Department of Pharmacy, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaolan Bian
- Department of Pharmacy, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Erzhen Chen
- Emergency Department, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Erzhen Chen,
| | - Juan He
- Department of Pharmacy, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Emergency Department, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Juan He,
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15
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Chan KS, Shelat VG. Diagnosis, severity stratification and management of adult acute pancreatitis–current evidence and controversies. World J Gastrointest Surg 2022; 14:1179-1197. [PMID: 36504520 PMCID: PMC9727576 DOI: 10.4240/wjgs.v14.i11.1179] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/08/2022] [Accepted: 10/25/2022] [Indexed: 02/07/2023] Open
Abstract
Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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16
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Wang Q, Chen Y, Huang P, Su D, Gao F, Fu X, Fu B. The Clinical Characteristics and Outcome of Elderly Patients With Acute Pancreatitis. Pancreas 2022; 51:1284-1291. [PMID: 37099768 DOI: 10.1097/mpa.0000000000002192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
OBJECTIVES This study aimed to identify the risk factors for the progression of acute pancreatitis (AP) to severe acute pancreatitis (SAP) and death in elderly patients. METHODS This was a single-center retrospective study conducted in a tertiary teaching hospital. Data on patient demographics, comorbidities, duration of hospitalization, complications, interventions, and mortality rates were collected. RESULTS Between January 2010 and January 2021, 2084 elderly patients with AP were included in this study. The mean age of the patients was 70.0 years (standard deviation, 7.1 years). Among them, 324 (15.5%) had SAP and 105 died (5.0%). The 90-day mortality rate in the SAP group was significantly higher than that in the AP group (P < 0.0001). Multivariate regression analysis revealed that trauma, hypertension, and smoking were risk factors for SAP. After multivariate adjustment, acute respiratory distress syndrome, acute kidney injury, sepsis, organ perforation, and abdominal hemorrhage were associated with higher 90-day mortality. CONCLUSIONS Traumatic pancreatitis, hypertension, and smoking are independent risk factors for SAP in elderly patients. Acute respiratory distress syndrome, acute kidney injury, sepsis, organ perforation, and abdominal hemorrhage are independent risk factors for death in elderly patients with AP.
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Jaber S, Garnier M, Asehnoune K, Bounes F, Buscail L, Chevaux JB, Dahyot-Fizelier C, Darrivere L, Jabaudon M, Joannes-Boyau O, Launey Y, Levesque E, Levy P, Montravers P, Muller L, Rimmelé T, Roger C, Savoye-Collet C, Seguin P, Tasu JP, Thibault R, Vanbiervliet G, Weiss E, Jong AD. Pancréatite aiguë grave du patient adulte en soins critiques 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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18
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Purschke B, Bolm L, Meyer MN, Sato H. Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes. World J Gastroenterol 2022; 28:3383-3397. [PMID: 36158258 PMCID: PMC9346450 DOI: 10.3748/wjg.v28.i27.3383] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/07/2022] [Accepted: 06/16/2022] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the “step-up approach”. This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.
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Affiliation(s)
- Birte Purschke
- Department of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Louisa Bolm
- Department of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Max Nikolaus Meyer
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Hiroki Sato
- Department of Medicine, Asahikawa Medical University, Asahikawa 0788510, Hokkaido, Japan
- Department of Gastroenterology, Asahikawa Kosei Hospital, Asahikawa 0788211, Hokkaido, Japan
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19
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Jaber S, Garnier M, Asehnoune K, Bounes F, Buscail L, Chevaux JB, Dahyot-Fizelier C, Darrivere L, Jabaudon M, Joannes-Boyau O, Launey Y, Levesque E, Levy P, Montravers P, Muller L, Rimmelé T, Roger C, Savoye-Collet C, Seguin P, Tasu JP, Thibault R, Vanbiervliet G, Weiss E, De Jong A. Guidelines for the management of patients with severe acute pancreatitis, 2021. Anaesth Crit Care Pain Med 2022; 41:101060. [PMID: 35636304 DOI: 10.1016/j.accpm.2022.101060] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To provide guidelines for the management of the intensive care patient with severe acute pancreatitis. DESIGN A consensus committee of 22 experts was convened. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS The most recent SFAR and SNFGE guidelines on the management of the patient with severe pancreatitis were published in 2001. The literature now is sufficient for an update. The committee studied 14 questions within 3 fields. Each question was formulated in a PICO (Patients Intervention Comparison Outcome) format and the relevant evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and their application of the GRADE® method resulted in 24 recommendations. Among the formalised recommendations, 8 have high levels of evidence (GRADE 1+/-) and 12 have moderate levels of evidence (GRADE 2+/-). For 4 recommendations, the GRADE method could not be applied, resulting in expert opinions. Four questions did not find any response in the literature. After one round of scoring, strong agreement was reached for all the recommendations. CONCLUSIONS There was strong agreement among experts for 24 recommendations to improve practices for the management of intensive care patients with severe acute pancreatitis.
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Affiliation(s)
- Samir Jaber
- Department of Anaesthesiology and Intensive Care (DAR B), University Hospital Center Saint Eloi Hospital, Montpellier, France; PhyMedExp, Montpellier University, INSERM, CNRS, CHU de Montpellier, Montpellier, France.
| | - Marc Garnier
- Sorbonne Université, GRC 29, DMU DREAM, Service d'Anesthésie-Réanimation et Médecine Périopératoire Rive Droite, Paris, France
| | - Karim Asehnoune
- Service d'Anesthésie, Réanimation chirurgicale, Hôtel Dieu/HME, CHU Nantes, Nantes cedex 1, France; Inserm, UMR 1064 CR2TI, team 6, France
| | - Fanny Bounes
- Toulouse University Hospital, Anaesthesia Critical Care and Perioperative Medicine Department, Toulouse, France; Équipe INSERM Pr Payrastre, I2MC, Université Paul Sabatier Toulouse III, Toulouse, France
| | - Louis Buscail
- Department of Gastroenterology & Pancreatology, University of Toulouse, Rangueil Hospital, Toulouse, France
| | | | - Claire Dahyot-Fizelier
- Anaesthesiology and Intensive Care Department, University hospital of Poitiers, Poitiers, France; INSERM U1070, University of Poitiers, Poitiers, France
| | - Lucie Darrivere
- Department of Anaesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, F-75010, Paris, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; iGReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France
| | - Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation SUD, CHU de Bordeaux, Hôpital Magellan, Bordeaux, France
| | - Yoann Launey
- Critical Care Unit, Department of Anaesthesia, Critical Care and Perioperative Medicine, University Hospital of Rennes, Rennes, France
| | - Eric Levesque
- Department of Anaesthesia and Surgical Intensive Care, AP-HP, Henri Mondor Hospital, Créteil, France; Université Paris-Est Creteil, EnvA, DYNAMiC, Faculté de Santé de Créteil, Creteil, France
| | - Philippe Levy
- Service de Pancréatologie et d'Oncologie Digestive, DMU DIGEST, Université de Paris, Hôpital Beaujon, APHP, Clichy, France
| | - Philippe Montravers
- Université de Paris Cité, INSERM UMR 1152 - PHERE, Paris, France; Département d'Anesthésie-Réanimation, APHP, CHU Bichat-Claude Bernard, DMU PARABOL, APHP, Paris, France
| | - Laurent Muller
- Réanimations et surveillance continue, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes Caremeau, Montpellier, France
| | - Thomas Rimmelé
- Département d'anesthésie-réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France; EA 7426: Pathophysiology of Injury-induced Immunosuppression, Pi3, Hospices Civils de Lyon-Biomérieux-Université Claude Bernard Lyon 1, Lyon, France
| | - Claire Roger
- Réanimations et surveillance continue, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes Caremeau, Montpellier, France; Department of Intensive care medicine, Division of Anaesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Céline Savoye-Collet
- Department of Radiology, Normandie University, UNIROUEN, Quantif-LITIS EA 4108, Rouen University Hospital-Charles Nicolle, Rouen, France
| | - Philippe Seguin
- Service d'Anesthésie Réanimation 1, Réanimation chirurgicale, CHU de Rennes, Rennes, France
| | - Jean-Pierre Tasu
- Service de radiologie diagnostique et interventionnelle, CHU de Poitiers, Poitiers, France; LaTim, UBO and INSERM 1101, University of Brest, Brest, France
| | - Ronan Thibault
- Service Endocrinologie-Diabétologie-Nutrition, CHU Rennes, INRAE, INSERM, Univ Rennes, NuMeCan, Nutrition Metabolisms Cancer, Rennes, France
| | - Geoffroy Vanbiervliet
- Department of Digestive Endoscopy, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France; University of Paris, Paris, France; Inserm UMR_S1149, Centre for Research on Inflammation, Paris, France
| | - Audrey De Jong
- Department of Anaesthesiology and Intensive Care (DAR B), University Hospital Center Saint Eloi Hospital, Montpellier, France; PhyMedExp, Montpellier University, INSERM, CNRS, CHU de Montpellier, Montpellier, France
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20
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Retroperitoneal versus transperitoneal percutaneous catheter drainage of necrotic pancreatic collections: a comparative analysis. Abdom Radiol (NY) 2022; 47:1899-1906. [PMID: 35286420 DOI: 10.1007/s00261-022-03476-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE To compare the success rate, clinical outcomes, and complications of retroperitoneal (RP) versus transperitoneal (TP) percutaneous catheter drainage (PCD) of the necrotic pancreatic fluid collections. MATERIALS AND METHODS This retrospective study comprised consecutive patients with acute pancreatitis who underwent PCD of lesser sac collections amenable to drainage via both TP and RP routes. The patients were divided into two groups based on the route of drainage (group I, RP, and group II, TP). The technical success, clinical success, complications, and clinical outcomes were compared between the groups. Subgroup analysis was performed based on the timing of drainage (acute necrotic collections, ANC vs. walled-off necrosis, WON) and organ failure (OF). RESULTS Seventy-nine patients [mean age, 38.7 ± 12.3 years, 54 males] were included in the study. Group I and II comprised 22 (27.8%) and 57 (72.2%) patients, respectively. The procedures were technically successful in all the patients. There was no significant difference in the complication rate between the two groups. The clinical success was higher in group II (75.4%) as compared to group I (54.5%). However, the difference was not statistically significant (p = 0.070). There was no significant difference in the hospital stay (p = 0.298), intensive care unit stay (p = 0.401), need for surgical necrosectomy (p = 0.243), and mortality (p = 0.112) between the two groups. The outcomes in patients with OF and ANC were not affected by the route of PCD. Clinical success rate was significantly higher in WON undergoing TP drainage (p = 0.009). CONCLUSION Both RP and TP routes of PCD are safe and effective. Clinical success rate was significantly higher in WON undergoing TP drainage.
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21
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Tran A, Fernando SM, Rochwerg B, Inaba K, Bertens KA, Engels PT, Balaa FK, Kubelik D, Matar M, Lenet TI, Martel G. Prognostic factors associated with development of infected necrosis in patients with acute necrotizing or severe pancreatitis-A systematic review and meta-analysis. J Trauma Acute Care Surg 2022; 92:940-948. [PMID: 34936587 DOI: 10.1097/ta.0000000000003502] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
PURPOSE Acute pancreatitis is a potentially life-threatening condition with a wide spectrum of clinical presentation and illness severity. An infection of pancreatic necrosis (IPN) results in a more than twofold increase in mortality risk as compared with patients with sterile necrosis. We sought to identify prognostic factors for the development of IPN among adult patients with severe or necrotizing pancreatitis. METHODS We conducted this prognostic review in accordance with systematic review methodology guidelines. We searched six databases from inception through March 21, 2021. We included English language studies describing prognostic factors associated with the development of IPN. We pooled unadjusted odds ratio (uOR) and adjusted odds ratios (aOR) for prognostic factors using a random-effects model. We assessed risk of bias using the Quality in Prognosis Studies tool and certainty of evidence using the GRADE approach. RESULTS We included 31 observational studies involving 5,210 patients. Factors with moderate or higher certainty of association with increased IPN risk include older age (uOR, 2.19; 95% confidence interval [CI], 1.39-3.45, moderate certainty), gallstone etiology (aOR, 2.35; 95% CI, 1.36-4.04, high certainty), greater than 50% necrosis of the pancreas (aOR, 3.61; 95% CI, 2.15-6.04, high certainty), delayed enteral nutrition (aOR, 2.09; 95% CI, 1.26-3.47, moderate certainty), multiple or persistent organ failure (aOR, 11.71; 95% CI, 4.97-27.56, high certainty), and invasive mechanical ventilation (uOR, 12.24; 95% CI, 2.28-65.67, high certainty). CONCLUSION This meta-analysis confirms the association between several clinical early prognostic factors and the risk of IPN development among patients with severe or necrotizing pancreatitis. These findings provide the foundation for the development of an IPN risk stratification tool to guide more targeted clinical trials for prevention or early intervention strategies. LEVEL OF EVIDENCE Systematic review and meta-analysis, Level IV.
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Affiliation(s)
- Alexandre Tran
- From the Department of Surgery (A.T., K.A.B., F.K.B., D.K., M.M., T.I.L., G.M.), School of Epidemiology and Public Health (A.T., T.I.L., G.M.), Division of Critical Care, Department of Medicine (A.T., S.M.F., D.K.), Department of Emergency Medicine (S.M.F.), University of Ottawa, Ottawa; Department of Medicine (B.R.), Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton, ON, Canada; Division of Acute Care Surgery, Department of Surgery (K.I.), University of Southern California, Los Angeles, California; Division of General Surgery, Department of Surgery (P.T.E.), and Division of Critical Care, Department of Medicine (P.T.E.), McMaster University, Hamilton, Canada
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22
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Stassen PMC, de Jonge PJF, Bruno MJ, Koch AD, Trindade AJ, Benias PC, Sejpal DV, Siddiqui UD, Chapman CG, Villa E, Tharian B, Inamdar S, Hwang JH, Barakat MT, Andalib I, Gaidhane M, Sarkar A, Shahid H, Tyberg A, Binmoeller K, Watson RR, Nett A, Schlag C, Abdelhafez M, Friedrich-Rust M, Schlachterman A, Chiang AL, Loren D, Kowalski T, Kahaleh M. Safety and efficacy of a novel resection system for direct endoscopic necrosectomy of walled-off pancreas necrosis: a prospective, international, multicenter trial. Gastrointest Endosc 2022; 95:471-479. [PMID: 34562471 DOI: 10.1016/j.gie.2021.09.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/10/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Direct endoscopic necrosectomy (DEN) of walled-off pancreatic necrosis (WOPN) lacks dedicated instruments and requires repetitive and cumbersome procedures. This study evaluated the safety and efficacy of a new powered endoscopic debridement (PED) system designed to simultaneously resect and remove solid debris within WOPN. METHODS This was a single-arm, prospective, multicenter, international device trial conducted from November 2018 to August 2019 at 10 sites. Patients with WOPN ≥6 cm and ≤22 cm and with >30% solid debris were enrolled. The primary endpoint was safety through 21 days after the last DEN procedure. Efficacy outcomes included clearance of necrosis, procedural time, adequacy of debridement, number of procedures until resolution, hospital stay duration, and quality of life. RESULTS Thirty patients (mean age, 55 years; 60% men) underwent DEN with no device-related adverse events. Of 30 patients, 15 (50%) achieved complete debridement in 1 session and 20 (67%) achieved complete debridement within 2 or fewer sessions. A median of 1.5 interventions (range, 1-7) were required. Median hospital stay was 10 days (interquartile range, 22). There was an overall reduction of 91% in percent necrosis within WOPN from baseline to follow-up and 85% in collection volume. Baseline WOPN volume was positively correlated with the total number of interventions (ρ = .363, P = .049). CONCLUSIONS The new PED system seems to be a safe and effective treatment tool for WOPN, resulting in fewer interventions and lower hospital duration when compared with published data on using conventional instruments. Randomized controlled trials comparing the PED system with conventional DEN are needed. (Clinical trial registration number: NCT03694210.).
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Affiliation(s)
- Pauline M C Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Petros C Benias
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Divyesh V Sejpal
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Uzma D Siddiqui
- The Center for Endoscopic Research and Therapeutics (CERT), University of Chicago Medicine, Chicago, Illinois, USA
| | - Christopher G Chapman
- The Center for Endoscopic Research and Therapeutics (CERT), University of Chicago Medicine, Chicago, Illinois, USA
| | - Edward Villa
- Division of Gastroenterology and Hepatology, University of Illinois at Chicago Medical Center, Chicago, Illinois, USA
| | - Benjamin Tharian
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Sumant Inamdar
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford University, Stanford, California, USA
| | - Monique T Barakat
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford University, Stanford, California, USA
| | - Iman Andalib
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Monica Gaidhane
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Avik Sarkar
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Haroon Shahid
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Amy Tyberg
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Kenneth Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Rabindra R Watson
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Andrew Nett
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Christoph Schlag
- Medical Department, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Mohamed Abdelhafez
- Medical Department, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine 1, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Alexander Schlachterman
- Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Austin L Chiang
- Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David Loren
- Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thomas Kowalski
- Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michel Kahaleh
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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23
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Qu C, Duan Z, Xiao X, Wei M, Gao K, Yu X, Ke L, Tong Z, Li W. Nonthyroidal illness syndrome in acute pancreatitis patients: an 8-year cohort study. BMC Gastroenterol 2022; 22:40. [PMID: 35114934 PMCID: PMC8812001 DOI: 10.1186/s12876-022-02111-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nonthyroidal illness syndrome (NTIS) is common in critical illness and is associated with poor prognosis. The aim of this study was to find the prevalence, charateristics, and prognosis of NTIS and its correlation with outcomes in AP patients. METHODS A retrospective review of AP patients with a diagnosis of NTIS from Jan 2012 to September 2020 was performed. The serum thyroidal hormone (TH) disturbances, as well as the demographic characteristics and clinical outcomes of the study patients, were collected and analyzed. RESULTS Over the eight years, 183 included AP patients were diagnosed as NTIS, constituting an incidence of 64.7%. Patients with NTIS were admitted with worse condition based on the higher APACHE II score, SOFA score, Balthazar's CT score, CRP and lower albumin than euthyroid patients. Also, these patients had a longer ICU duration (3, 2-10 vs 2, 0-3, days, P = 0.039) and tended to be more likely to develop infected pancreatic necrosis (IPN) (15.3% vs 6.3%, P = 0.087) and gastrointestinal fistula (6% vs 0%, P = 0.082) than euthyroid patients. Free triiodothyronine (FT3) was found the best performance in predicting death compared by other well-recognized biomarkers. CONCLUSION NTIS is common in AP patients within 7 days after the onset of the disease. NTIS is associated with the worse characteristics at admission and poor outcome during the course. FT3 should be investigate as a potential biomarker in the prediction of death in AP patients.
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Affiliation(s)
- Cheng Qu
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Jiangsu Province, China
| | - Zehua Duan
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Jiangsu Province, China
| | - Xiaojia Xiao
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Clinical Medical College of Southern Medical University, Nanjing, 210002, China
| | - Mei Wei
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Jiangsu Province, China
| | - Kun Gao
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Clinical Medical College of Nanjing Medical University, Nanjing, 210002, China
| | - Xianqiang Yu
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Clinical Medical College of Southeast University, Nanjing, 210002, China
| | - Lu Ke
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Jiangsu Province, China
| | - Zhihui Tong
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Jiangsu Province, China. .,Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Clinical Medical College of Southern Medical University, Nanjing, 210002, China.
| | - Weiqin Li
- Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002, Jiangsu Province, China.,Center of Severe Acute Pancreatitis (CSAP), Department of General Surgery, Jinling Clinical Medical College of Southern Medical University, Nanjing, 210002, China
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24
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Formanchuk T, Shaprinskiy V, Formanchuk A. Clinical and simple laboratory data associated with fatal outcomes in patients with acute pancreatitis. ACTA FACULTATIS MEDICAE NAISSENSIS 2022. [DOI: 10.5937/afmnai39-32308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Aims. The aim of the study was to evaluate the association of mortality in acute pancreatitis with clinical and simple laboratory data received on the day of admission. Patients and methods. In our retrospective study, the clinical and laboratory parameters of 99 patients with moderate and severe acute pancreatitis were analyzed. All patients were divided into two groups: deceased and survivors. Results. We did not find a significant difference in age and gender distribution between the comparison groups. However, a significant predominance of alcoholic etiology of acute pancreatitis, early hospitalization (up to 6 hours from the onset of the disease) of patients, and the number of necrotizing infected type in the deceased group were found. Concomitant pathology did not significantly differ in comparison groups. In patients from the deceased group, the total number of all complications was significantly higher than in the group of survivors-21 (100%) and 42 (53.8%) (p = 0.0001), respecting. Among the laboratory parameters determined on the day of admission, in the deceased group, there was a significant increase in stabs to 19.8 ± 9.8 and ESR, AST to 225.3 ± 47.5 U/L, urea to 11.2 ± 7.7 mmol/L, and creatinine to 173.6 ± 26.1 mmol/L. Conclusion. The alcoholic genesis of acute pancreatitis, necrotizing infected type of inflammation of the pancreas, presence of late complications, and comorbidities were significantly higher in the deceased group. The levels of stabs, ESR, AST, urea, and creatinine determined on the admission significantly dominated in the deceased group, which requires further study for the prediction of mortality of acute pancreatitis.
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25
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Fedorov AV, Ektov VN, Khodorkovsky MA. [Disconnected pancreatic duct syndrome in acute pancreatitis]. Khirurgiia (Mosk) 2022:83-89. [PMID: 35920227 DOI: 10.17116/hirurgia202208183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The review is devoted to diagnosis and treatment of disconnected pancreatic duct syndrome (DPDS) in patients with acute pancreatitis. Data on terminology, indications and options for endoscopic transluminal interventions are presented in detail. The results of numerous studies evaluating clinical efficacy of various endoscopic and open surgical procedures are analyzed. Available data confirm advisability of staged treatment of DPDS with primary endoscopic drainage of pancreatic fluid accumulations in specialized centers.
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Affiliation(s)
- A V Fedorov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - V N Ektov
- Burdenko Voronezh State Medical University, Voronezh, Russia
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26
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Nougnignon Comlan Deguenonvo G, Thiam I. [Multivisceral pancratic cytosteatonecrosis found at autopsy]. Ann Pathol 2021; 42:424-427. [PMID: 34920904 DOI: 10.1016/j.annpat.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/21/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Pancreatic cytosteatonecrosis is a rare condition associated with various pancreatic diseases such as acute or chronic pancreatitis and pancreatic cancer. We report a case of pancreatic cytosteatonecrosis discovered at autopsy. OBSERVATION This is a young man, 29 years old, alcoholic, non-smoker, who consulted for abdominal pain, vomiting, fever (38°). Renal ultrasound showed signs of acute renal failure, with severe anemia at 6g/dl and hyperleukocytosis. Lipasemia has not been tested. The treatment combined hemodialysis, punctures of effusions, analgesics, antibiotics and diuretics. The death occurred after 45 days of hospitalization. The medical autopsy requested showed an abdominal cavity dotted with multiple whitish, chalky, "candle-stained" nodules scattered throughout the peritoneum. Microscopy confirmed the diagnosis by showing large areas of adiponecrosis associated with polymorphic, diffuse leukocyte infiltrates and calcifications. CONCLUSION This observation is original by the discovery at autopsy of one of the major complications of acute pancreatitis. This situation is dramatic because the death could be avoided. You have to think about it in order to ask for the dosage of lipasemia. The "digestion" of pancreatic enzymes are responsible for intra-pancreatic and peri-pancreatic complications. Chronic alcoholism and cholelithiasis are the main risk factors.
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Affiliation(s)
| | - Ibou Thiam
- Laboratoire d'anatomie et de cytologie pathologiques, Pavillon Bichat, C.H.N.U. Aristide Le DANTEC, avenue Pasteur, BP : 3001, Dakar, Sénégal
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27
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Wen H, Li Q, Lu N, Su YY, Ma PH, Zhang MX. Intestinal flora and pancreatitis: Present and future. Shijie Huaren Xiaohua Zazhi 2021; 29:1269-1275. [DOI: 10.11569/wcjd.v29.i22.1269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The role of intestinal flora in human health and diseases has attracted more and more attention. At present, there have been some reports on the relationship between intestinal flora and pancreatitis. These reports reveal that intestinal flora plays some important roles in the occurrence and development of pancreatitis. The specific mechanisms of action are unclear, but there is preliminary consensus that intestinal microbiome dysregulation promotes inflammatory changes in the pancreas. This paper summarizes the correlation between intestinal flora and pancreatitis, in order to provide some references and ideas for further research.
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Affiliation(s)
- Hua Wen
- Xi'an Medical University, Xi'an 710000, Shaanxi Province, China,Department of Gastroenterology, The First Affiliated Hospital of Xi'an Medical University, Xi'an 710077, Shaanxi Province, China
| | - Qian Li
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Medical University, Xi'an 710077, Shaanxi Province, China
| | - Ning Lu
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Medical University, Xi'an 710077, Shaanxi Province, China
| | - Yuan-Yuan Su
- Xi'an Medical University, Xi'an 710000, Shaanxi Province, China,Department of Gastroenterology, The First Affiliated Hospital of Xi'an Medical University, Xi'an 710077, Shaanxi Province, China
| | - Pei-Han Ma
- The Second Clinical Medical College, Shaanxi University of Traditional Chinese Medicine, Xianyang 712046, Shaanxi Province, China
| | - Ming-Xin Zhang
- The Second Clinical Medical College, Shaanxi University of Traditional Chinese Medicine, Xianyang 712046, Shaanxi Province, China
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28
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Tahir H, Rahman S, Habib Z, Khan Y, Shehzad S. Comparison of the Accuracy of Modified CT Severity Index Score and Neutrophil-to-Lymphocyte Ratio in Assessing the Severity of Acute Pancreatitis. Cureus 2021; 13:e17020. [PMID: 34522501 PMCID: PMC8425492 DOI: 10.7759/cureus.17020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2021] [Indexed: 12/13/2022] Open
Abstract
Background Acute pancreatitis is an acute gastrointestinal emergency with significant morbidity and mortality if not treated. It can lead to local as well as systemic complications and has a prevalence of 51.07%. Laboratory investigations such as amylase and lipase and ultrasound scan are typically used for the diagnosis. A contrast-enhanced CT scan is considered the gold standard. Both laboratory and radiological investigation-based scoring systems have been reported in the literature and are in practice. However, these modalities demand several laboratory investigations and are expensive. Our study aims to determine the congruency of the neutrophil-to-lymphocyte ratio (NLR) and the modified CT severity index score (MCTSI) with the revised Atlanta classification in assessing the severity of acute pancreatitis. In addition, the accuracy of NLR and MCTSI is determined. The secondary objective is to determine whether NLR can predict the severity of acute pancreatitis to the same extent as MCTSI through expensive radiological imaging and other clinical scoring systems through a list of investigations. Methodology The data for this study were collected retrospectively and patients with a diagnosis of acute pancreatitis were included through the nonprobability convenience sampling method. All patients underwent relevant laboratory workup (including complete blood count) and radiological workup (including CT scan) during their hospital stay. The main outcome measures were sensitivity, specificity, and accuracy of NLR and MCTSI, and the congruency of these with the revised Atlanta classification in assessing the severity of acute pancreatitis. Results A total of 166 patients with acute pancreatitis were included, of which 107 (64.45%) were males and 59 (35.55%) were females, with a mean age of 43.7. The sensitivity, specificity, and accuracy of NLR were 67%, 90.9%, and 76%, respectively, whereas the sensitivity, specificity, and accuracy of MCTSI were 95%, 13.6%, and 62%, respectively. The area under the curve for NLR was 0.855 whereas that for MCTSI was determined to be 0.645. Conclusions NLR has a good concordance with the revised Atlanta classification and assesses the disease severity, especially in moderate-to-severe cases of acute pancreatitis compared to MCTSI. In addition, NLR can be used in acute and/or resource-poor settings to predict the severity of acute pancreatitis.
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Affiliation(s)
- Hasan Tahir
- Department of Plastic and Reconstructive Surgery, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Sheeraz Rahman
- Department of General Surgery, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Zahid Habib
- Department of General Surgery, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Yusra Khan
- General Surgery, Karachi Medical and Dental College, Karachi, PAK
| | - Saleha Shehzad
- Department of Radiology, Liaquat National Hospital and Medical College, Karachi, PAK
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29
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Sahu B, Abbey P, Anand R, Kumar A, Tomer S, Malik E. Severity assessment of acute pancreatitis using CT severity index and modified CT severity index: Correlation with clinical outcomes and severity grading as per the Revised Atlanta Classification. Indian J Radiol Imaging 2021; 27:152-160. [PMID: 28744075 PMCID: PMC5510312 DOI: 10.4103/ijri.ijri_300_16] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
AIMS To assess the severity of acute pancreatitis (AP) using computed tomography (CT) severity index (CTSI) and modified CT severity index (MCTSI), to correlate with clinical outcome measures, and to assess concordance with severity grading, as per the revised Atlanta classification (RAC). MATERIALS AND METHODS In this prospective study approved by the Institutional Review Board (November 2014 to March 2016), sixty patients with AP (as per the RAC definition) underwent contrast-enhanced computed tomography (CECT) 5-11 days (median 6 days) after symptom onset. Two radiologists, blinded to clinical parameters, independently assessed CTSI and MCTSI (differences were resolved by consensus). Clinical outcome parameters included duration of stay in the hospital and intensive care unit (ICU), presence of persistent organ failure (OF), evidence of infection, need for intervention, and mortality. RESULTS We included 60 cases [36 males, age range 19-65 (mean 37) years]. As per the RAC, 26 patients had mild AP, 12 moderately severe, and 22 severe AP. According to CTSI and MCTSI, mild, moderate, and severe cases were 27 (45%), 19 (31.7%), 14 (23.3%) and 24 (40%), 10 (16.7%), 26 (43.3%), respectively. MCTSI was concordant with the RAC grading in 54 (90.0%), CTSI was concordant in 47 (78.3%), and both were concordant in 43 (71.7%) cases. Area under the receiver-operating characteristic (ROC) curves (AUROC) was compared by the Hanley and McNeil method. Both CTSI and MCTSI were significantly associated with outcome parameters (P < 0.001), except duration of ICU stay. Sensitivity, specificity, positive predictive value (PPV), and accuracy of CTSI for detecting moderate/severe disease were 97.1%, 100%, 100%, and 98.3% respectively, and of MCTSI were 100%, 92.3%, 94.4%, and 96.7% respectively. CONCLUSION Both CTSI and MCTSI showed significant correlation with clinical outcome parameters, and good concordance with RAC grading of severity. MCTSI showed a higher sensitivity but lower specificity than CTSI in differentiating mild from moderate/severe AP.
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Affiliation(s)
- Biswanath Sahu
- Department of Radio-Diagnosis, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
| | - Pooja Abbey
- Department of Radio-Diagnosis, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
| | - Rama Anand
- Department of Radio-Diagnosis, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
| | - Ashok Kumar
- Department of Surgery, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
| | - Shaili Tomer
- Department of Radio-Diagnosis, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
| | - Ekta Malik
- Department of Biochemistry, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
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Thiruvengadam NR, Miranda J, Kim C, Behr S, Arain MA. The Pancreatitis Activity Scoring System Predicts Clinical Outcomes in Patients With Infected Pancreatic Necrosis. Pancreas 2021; 50:859-866. [PMID: 34347734 DOI: 10.1097/mpa.0000000000001838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The Pancreatitis Activity Scoring System (PASS) is an objective tool validated in acute pancreatitis but not in infected pancreatic necrosis (IPN). Our aim was to evaluate the role of PASS in IPN. METHODS We performed a retrospective cohort study of IPN patients admitted to the University of California, San Francisco from January 2011 to March 2019. Daily PASS scores were calculated for each patient. Receiver operator characteristic analysis was used to define the optimal cutoff PASS score to predict outcomes. The primary and secondary outcomes were 72 hours postintervention multiorgan failure (MOF) and early readmission (within 30 days), respectively. RESULTS One hundred and four patients underwent intervention (median age, 55 years). Thirty-five patients (33.6%) developed MOF postintervention. A 72-hour postintervention PASS greater than 250 was strongly associated with postintervention MOF (area under curve, 0.87; adjusted odds ratio, 26.83; 95% confidence interval, 6.37-112.86; P < 0.001). Discharge PASS greater than 150 was associated with 30-day readmission (area under curve, 0.82; adjusted odds ratio, 26.44; 95% confidence interval, 8.48-82.43; P < 0.001). CONCLUSIONS The PASS score was associated with postintervention clinical outcomes and early readmission, suggesting it is a valid measure of disease activity in patients with IPN. Further prospective validation of PASS in IPN is needed.
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Affiliation(s)
| | | | - Christopher Kim
- Abdominal Imaging Section, Department of Radiology, University of California San Francisco, San Francisco, CA
| | - Spencer Behr
- Abdominal Imaging Section, Department of Radiology, University of California San Francisco, San Francisco, CA
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Gut microbiota in pancreatic diseases: possible new therapeutic strategies. Acta Pharmacol Sin 2021; 42:1027-1039. [PMID: 33093569 DOI: 10.1038/s41401-020-00532-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022] Open
Abstract
Pancreatic diseases such as pancreatitis, type 1 diabetes and pancreatic cancer impose substantial health-care costs and contribute to marked morbidity and mortality. Recent studies have suggested a link between gut microbiota dysbiosis and pancreatic diseases; however, the potential roles and mechanisms of action of gut microbiota in pancreatic diseases remain to be fully elucidated. In this review, we summarize the evidence that supports relationship between alterations of gut microbiota and development of pancreatic diseases, and discuss the potential molecular mechanisms of gut microbiota dysbiosis in the pathogenesis of pancreatic diseases. We also propose current strategies toward gut microbiota to advance a developing research field that has clinical potential to reduce the cost of pancreatic diseases.
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Fujiwara J, Matsumoto S, Sekine M, Mashima H. C-reactive protein predicts the development of walled-off necrosis in patients with severe acute pancreatitis. JGH OPEN 2021; 5:907-914. [PMID: 34386599 PMCID: PMC8341195 DOI: 10.1002/jgh3.12605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/01/2021] [Accepted: 06/22/2021] [Indexed: 11/17/2022]
Abstract
Background and Aim Walled‐off necrosis (WON) is reported to occur in 1–9% of patients with acute pancreatitis. However, the factors associated with the onset of this condition have not been elucidated. This study aimed to investigate the potential predictive factors for WON in patients diagnosed with severe acute pancreatitis at our hospital. Methods This study included 26 patients with severe acute pancreatitis identified among the 211 patients with acute pancreatitis admitted to our hospital between January 2014 and December 2018. Patients with and without WON (WON and non‐WON groups, respectively) were compared to identify potential factors involved in the onset of this condition. Results The 26 patients had a median age of 67 years, and 65% were male. WON occurred in 15 patients (57.7%). In a univariate analysis, the WON and non‐WON groups differed significantly in terms of maximum C‐reactive protein (CRP) levels (median) (322.7 mg/L vs 163.8 mg/L [P = 0.001]). In a multivariate analysis, a significant association was identified between the maximum CRP level and the onset of WON (odds ratio: 1.20, 95% confidence interval: 1.05–1.37). The CRP level peaked within 3 days in 88%. Conclusion The maximum CRP level was identified as a predictive factor for the onset of WON, and a high proportion of patients with WON exhibited elevated CRP levels within 3 days after diagnosis. This work suggests the clinical importance of continuous monitoring at an early stage after diagnosis to identify the maximum CRP level.
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Affiliation(s)
- Junichi Fujiwara
- Department of Gastroenterology, Saitama Medical Center Jichi Medical University Saitama-shi Saitama Japan
| | - Satohiro Matsumoto
- Department of Gastroenterology, Saitama Medical Center Jichi Medical University Saitama-shi Saitama Japan
| | - Masanari Sekine
- Department of Gastroenterology, Saitama Medical Center Jichi Medical University Saitama-shi Saitama Japan
| | - Hirosato Mashima
- Department of Gastroenterology, Saitama Medical Center Jichi Medical University Saitama-shi Saitama Japan
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Betulinic Acid Ameliorates the Severity of Acute Pancreatitis via Inhibition of the NF-κB Signaling Pathway in Mice. Int J Mol Sci 2021; 22:ijms22136871. [PMID: 34206763 PMCID: PMC8268208 DOI: 10.3390/ijms22136871] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 02/07/2023] Open
Abstract
Acute pancreatitis (AP) is an inflammatory disorder, involving acinar cell death and the release of inflammatory cytokines. Currently, there are limited effective therapeutic agents for AP. Betulinic acid (BA) is a pentacyclic triterpenoid extracted from Betula platyphylla that has been shown to have anti-inflammatory effects. In this study, we aimed to investigate the effects of BA on AP and elucidate the potential underlying mechanisms. AP was induced in mice through six intraperitoneal injections of cerulein. After the last cerulein injection, the mice were sacrificed. Our results revealed that pre- and post-treatment with BA significantly reduced the severity of pancreatitis, as evidenced by a decrease in histological damage in the pancreas and lung, serum amylase and lipase activity and pancreatic myeloperoxidase activity. Furthermore, BA pretreatment reduced proinflammatory cytokine production, augmentation of chemokines, and infiltration of macrophages and neutrophils in the pancreas of AP mice. In addition, mice that were pretreated with BA showed a reduction in Iκ-Bα degradation and nuclear factor-kappa B (NF-κB) binding activity in the pancreas. Moreover, BA reduced the production of proinflammatory cytokines and NF-κB activation in pancreatic acinar cells (PACs). These findings suggest that BA may have prophylactic and therapeutic effects on AP via inhibition of the NF-κB signaling pathway.
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Ingraham NE, King S, Proper J, Siegel L, Zolfaghari EJ, Murray TA, Vakayil V, Sheka A, Feng R, Guzman G, Roy SS, Muddappa D, Usher MG, Chipman JG, Tignanelli CJ, Pendleton KM. Morbidity and Mortality Trends of Pancreatitis: An Observational Study. Surg Infect (Larchmt) 2021; 22:1021-1030. [PMID: 34129395 DOI: 10.1089/sur.2020.473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Pancreatitis accounts for more than $2.5 billion of healthcare costs and remains the most common gastrointestinal (GI) admission. Few contemporary studies have assessed temporal trends of incidence, complications, management, and outcomes for acute pancreatitis in hospitalized patients at the national level. Methods: We used data from one of the largest hospital-based databases available in the United States, the Healthcare Cost and Utilization Project's (HCUP) State Inpatient Database, from 10 states between 2008 and 2015. We included patients with a diagnosis of acute pancreatitis (ICD-9 CM 577.0). Patient- and hospital-level data were used to estimate incidence and inpatient mortality rates. Results: From 80,736,256 hospitalizations, 929,914 (1.15%) cases of acute pancreatitis were identified, 186,226 (20.2%) of which were caused by gallbladder disease). The median age was 53 years (interquartile range [IQR], 41-67) and 50.8% were men. In-hospital mortality was 2.5% and crude mortality rates declined from 2.9% to 2.0% over the study period. Admission year remained significant after adjusting for patient demographics and comorbidities (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.89-0.90; p < 0.001). Gallbladder disease was associated with decreased odds of mortality (OR, 0.60; 95% CI, 0.57-0.62). Median length of stay was four days (IQR, 2-7) and decreased over time. The rates of surgical and endoscopic interventions were highest in 2011 (peak incidence of 16.1% and 9.5%, respectively) and have been decreasing since. Surgical providers were, on average, more likely than medical providers to perform surgery in both those with and without gallbladder disease etiology (gallbladder disease OR, 7.11; 95% CI, 5.46-9.25; non-gallbladder disease OR, 20.50; 95% CI, 16.81-25.01), endoscopy (gallbladder disease OR, 1.22; 95% CI, 0.87-1.72; non-gallbladder disease OR, 1.60; 95% CI, 1.18-2.16), or both (gallbladder disease OR, 7.00; 95% CI, 5.22-9.37; non-gallbladder disease OR, 8.85; 95% CI, 5.61-13.96). Conclusions: The incidence of pancreatitis, from 2008 to 2015, has increased whereas inpatient mortality (i.e., case fatality) has decreased. Understanding temporal trends in outcomes and management along with provider, hospital, and regional variation can better identify areas for future research and collaboration in managing these patients.
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Affiliation(s)
- Nicholas E Ingraham
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Samantha King
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jennifer Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Victor Vakayil
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Adam Sheka
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ruoying Feng
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gabriel Guzman
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Samit Sunny Roy
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Dhannanjay Muddappa
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael G Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jeffrey G Chipman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA.,Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathryn M Pendleton
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Abstract
Purpose: A retrospective study was first performed to assess the multidrug resistant (MDR) pathogen in severe acute pancreatitis (SAP) patients who were treated using the step-up approach. We aim to assess the risk factors between MDR pathogen and potential covariates in SAP patients. Methods: The clinical data of 51 SAP patients who were treated from June, 2013 to December, 2016 were retrospectively collected. A total of 23 patients in the MDR group and 28 patients in the non-MDR group were reviewed. The risk factors for MDR pathogen-induced infections in SAP patients were analyzed. Results: Hyperlipidemia was the leading cause of SAP in our study. The mean duration of hospital stay was significantly longer in the patients with MDR pathogen infections (P=0.0135). The hospitalization expenses of MDR group were much higher than those in non-MDR group. The mortality of MDR group (56.5%) was higher than that in non-MDR group (28.6%) (P=0.0436). Gram-negative isolates (63.8%) were commonly detected in SAP patients. Acinetobacter baumannii was the most common MDR pathogens. Systemic disease (P = 0.0136), initial use of carbapenem (P = 0.0438), and open necrosectomy (P = 0.0002) were the potential risk factors for MDR pathogen-induced infections in SAP. Furthermore, the logistic regression analysis revealed that open necrosectomy was the independent variable for MDR infections (OR: 15.6, 95% CI: 2.951–82.469, P = 0.0012). Conclusions: MDR pathogen-induced infections were common in SAP patients and Acinetobacter baumannii was the main pathogen. Meanwhile, open necrosectomy was the independent risk factor for the infection of MDR pathogen.
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Minkov G, Dimitrov E, Yovtchev Y, Enchev E, Lokova R, Halacheva K. Prognostic value of peripheral blood CD14+HLA-DR+ monocytes in patients with acute pancreatitis. J Immunoassay Immunochem 2021; 42:478-492. [PMID: 33818295 DOI: 10.1080/15321819.2021.1903491] [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] [Indexed: 01/11/2023]
Abstract
Acute pancreatitis (AP) is characterized by a potent pro-inflammatory response and concomitant anti-inflammatory response leading to a state of immunosuppression. Decreased HLA (Human Leukocyte Antigen)-DR expression on monocytes is a reliable cellular marker of immune suppression. The main objective of this study was to investigate the clinical value of the percentage of peripheral blood CD14+ HLA-DR+ monocytes (mHLA-DR) for diagnosis and assessment of severity, development of organ failures (OF), local complications (LC), and infected necrosis (IN), and outcome in patients with AP. Flow cytometry was used to measure the percentage of peripheral blood mHLA-DR at different time points in 82 patients with AP enrolled during the period of 2012-2018 admitted to University Hospital Stara Zagora, Bulgaria. The percentages of peripheral blood mHLA-DR in AP patients were significantly associated with severity, development of LC, OF, IN (measured at admission, on the 48th hour and on the 5th day) and with outcome (measured on the 5th day) of AP. The value of peripheral blood mHLA-DR may be used as a biological marker in the diagnosis and assessment of severity, development of OF, LC, IN and to predict outcome in AP.
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Affiliation(s)
- Georgi Minkov
- Department of Surgery, University Hospital "Prof. Dr. Stoyan Kirkovich" Stara Zagora, Bulgaria
| | - Evgeni Dimitrov
- Department of Surgery, University Hospital "Prof. Dr. Stoyan Kirkovich" Stara Zagora, Bulgaria
| | - Yovcho Yovtchev
- Department of Surgery, University Hospital "Prof. Dr. Stoyan Kirkovich" Stara Zagora, Bulgaria
| | - Emil Enchev
- Department of Surgery, University Hospital "Prof. Dr. Stoyan Kirkovich" Stara Zagora, Bulgaria
| | - Rumyana Lokova
- Laboratory of Clinical Immunology, University Hospital "Prof. Dr. Stoyan Kirkovich" Stara Zagora, Bulgaria
| | - Krasimira Halacheva
- Laboratory of Clinical Immunology, University Hospital "Prof. Dr. Stoyan Kirkovich" Stara Zagora, Bulgaria
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Early Changes in Blood Urea Nitrogen (BUN) Can Predict Mortality in Acute Pancreatitis: Comparative Study between BISAP Score, APACHE-II, and Other Laboratory Markers-A Prospective Observational Study. Can J Gastroenterol Hepatol 2021; 2021:6643595. [PMID: 33824864 PMCID: PMC8007377 DOI: 10.1155/2021/6643595] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/06/2021] [Accepted: 03/13/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Changes in BUN have been proposed as a risk factor for complications in acute pancreatitis (AP). Our study aimed to compare changes in BUN versus the Bedside Index for Severity in Acute Pancreatitis (BISAP) score and the Acute Physiology and Chronic Health Evaluation-II score (APACHE-II), as well as other laboratory tests such as haematocrit and its variations over 24 h and C-reactive protein, in order to determine the most accurate test for predicting mortality and severity outcomes in AP. METHODS Clinical data of 410 AP patients, prospectively enrolled for study at our institution, were analyzed. We define AP according to Atlanta classification (AC) 2012. The laboratory test's predictive accuracy was measured using area-under-the-curve receiver-operating characteristics (AUC) analysis and sensitivity and specificity tests. RESULTS Rise in BUN was the only score related to mortality on the multivariate analysis (p=0.000, OR: 12.7; CI 95%: 4.2-16.6). On the comparative analysis of AUC, the rise in BUN was an accurate test in predicting mortality (AUC: 0.842) and persisting multiorgan failure (AUC: 0.828), similar to the BISAP score (AUC: 0.836 and 0.850) and APACHE-II (AUC: 0.756 and 0.741). The BISAP score outperformed both APACHE-II and rise in BUN at 24 hours in predicting severe AP (AUC: 0.873 vs. 0.761 and 0.756, respectively). CONCLUSION Rise in BUN at 24 hours is a quick and reliable test in predicting mortality and persisting multiorgan failure in AP patients.
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Prajapati R, Manay P, Sugumar K, Rahandale V, Satoskar R. Acute pancreatitis: predictors of mortality, pancreatic necrosis and intervention. Turk J Surg 2021; 37:13-21. [PMID: 34585089 PMCID: PMC8448565 DOI: 10.47717/turkjsurg.2021.5072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/31/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Several predictive scoring systems are used in the prognostication of acute pancreatitis (AP). However, the quantity of evidence of these prognostic systems in the Indian population remains sparse. The aim of our study was to evaluate the usefulness of such prognostic scores to predict mortality, incidence of pancreatic necrosis and intervention in AP. MATERIAL AND METHODS This was an observational study of patients diagnosed with AP between June 2012 and November 2013 in a tertiary referral center in India. Vital signs, biochemical tests and CT-findings were recorded to identify SIRS, Ranson's score and CT-severity index at diagnosis. Chi square test was used to compare incidence of mortality, pancreatic necrosis, and intervention between mild versus severe acute pancreatitis groups. RESULTS A total of 100 patients with AP were treated during out study period. Ranson's score more than 7 and presence of pancreatic necrosis were significantly associated with increased mortality (p <0.05). SIRS, CTSI score more than 7, inotropic support, and complications were more frequently associated with patients with necrosis. Prophylactic antibiotics did not decrease mortality, but decreased intervention rate (p <0.05). Presence of systemic inflammatory response syndrome (SIRS), Ranson's score > 7, necrosis, inotropic support and presence of complications were associated with a greater rate of interventions including surgery and percutaneous procedures (p <0.05). CONCLUSION We validate SIRS, Ranson's, and CTSI score as prognostic markers for AP in the Indian population. These predictors, when used in combination, can direct early monitoring and aggressive management in order to decrease mortality associated with severe AP.
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Affiliation(s)
- Ramlal Prajapati
- Department of Surgery, University Hospitals, Seidman Cancer Center, Cleveland, United States
| | - Priyadarshini Manay
- Department of Transplant Surgery, University of Iowa Hospitals & Clinics, Iowa City, United States
| | - Kavin Sugumar
- Department of Surgery, University Hospitals, Seidman Cancer Center, Cleveland, United States
| | - Vinay Rahandale
- Department of Surgery, Seth G.S Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Rajeev Satoskar
- Department of Surgery, Seth G.S Medical College and King Edward Memorial Hospital, Mumbai, India
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Mannan F, Gill RC, Sohail AA, Alvi R, Ahmad K. Acute necrotizing pancreatitis: Has conservative management replaced surgery? Perspective from a tertiary care centre in Pakistan: A cross-sectional study. Ann Med Surg (Lond) 2021; 63:102159. [PMID: 33664946 PMCID: PMC7905362 DOI: 10.1016/j.amsu.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023] Open
Abstract
Background The main purpose of this study was to review the trends in management of patients presenting with acute necrotizing pancreatitis (ANP) over the last seven years and its effect on morbidity and mortality. Methods A cross-sectional study was conducted on all patients presenting with the diagnosis of acute necrotizing pancreatitis to the Aga Khan University Hospital in between the year 2008-2015. The study population was broadly categorized in to two groups based on the way these were managed. The first group consisted of patient who underwent surgery for acute necrotizing pancreatitis while the second group was composed of those patients with necrotizing pancreatitis who were conservatively managed. Patient outcomes were assessed in terms of hospital stay, complication rates and in-hospital mortality. Data was analyzed using SPSS version 20. Comparison of outcomes between two groups was done using chi-square test, Fischer exact test or t-test wherever applicable. A p-value of less than 0.05 was considered statistically significant. Results A total of n = 110 patients were included in the study with 68% (n = 75) males and 32% (n = 35) females. Nasojejunal route was found to be the most commonly utilized route of feeding in these patients consisting of around 49% (n = 54) patients with forty percent (n = 44) tolerating direct oral diet. The outcomes in both these groups in terms of hospital stay, complication rate, and in hospital mortality were not found to be statistically significant. The conservative group however was significant in terms of cost-effectiveness which was shown by a p value of (0.035). The management of this clinically important disease over the years showed an increased trend towards conservative approach in our institute. Conclusion Our study further substantiates the recent global trend of conservative approach towards managing patients with acute necrotizing pancreatitis as reflected in the recent available literature. Therefore surgeons of the developing world need to evolve and adapt to these new measures for better outcomes in patient management.
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Bansod S, Godugu C. Nimbolide ameliorates pancreatic inflammation and apoptosis by modulating NF-κB/SIRT1 and apoptosis signaling in acute pancreatitis model. Int Immunopharmacol 2020; 90:107246. [PMID: 33310297 DOI: 10.1016/j.intimp.2020.107246] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/25/2020] [Accepted: 11/25/2020] [Indexed: 12/12/2022]
Abstract
Acute pancreatitis (AP) is a potential gastrointestinal problem most commonly associated with pancreatic inflammation and acinar cells injury. Nimbolide (NB), isolated from the tree Azadirachta indica, possesses antioxidant and anti-inflammatory effects. Here, we aimed to investigate the pancreatic protective effects of NB in ameliorating cerulein-induced pancreatic inflammation and apoptosis in AP model and evaluate the potential mechanism of action. AP was induced in Swiss albino mice by six-hourly intraperitoneal exposures of cerulein (50 µg/kg/hr) and pre-treatment of NB (0.3 and 1 mg/kg) 7 days prior to the cerulein exposure. Various parameters associated with AP in plasma and pancreatic tissues were evaluated. Severity of AP was effectively ameliorated by NB as shown by reducing pancreatic edema, plasma amylase and lipase levels, MPO levels and in cerulein-induced histological damage. Further, the antioxidant effect of NB was associated with a significant inhibition of oxidative-nitrosative stress in Raw 264.7 cells and cerulein-induced AP mice. Moreover, NB suppressed proinflammatory cytokines, iNOS and nitrotyrosine expression. In addition, NB inhibited NF-κB activation and increased SIRT1 expression in cerulein challenged mice. Furthermore, NB also inhibited pancreatic apoptosis by downregulating cleaved caspase 3 and Bax while upregulating Bcl2 expression in cerulein-treated mice. Inhibition of pancreatic inflammation and apoptosis resulted in attenuation of cerulein-induced AP. These results suggest that NB exerts strong anti-pancreatitis effects against cerulein-induced AP by combating inflammatory and apoptosis signaling via SIRT1 activation.
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Affiliation(s)
- Sapana Bansod
- Department of Regulatory Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Balanagar, Hyderabad, Telangana, India
| | - Chandraiah Godugu
- Department of Regulatory Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Balanagar, Hyderabad, Telangana, India.
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Wang YH. Current progress of research on intestinal bacterial translocation. Microb Pathog 2020; 152:104652. [PMID: 33249165 DOI: 10.1016/j.micpath.2020.104652] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/19/2020] [Accepted: 11/24/2020] [Indexed: 02/07/2023]
Abstract
Under normal conditions, the intestinal flora and the body are in dynamic equilibrium. When the barrier function of the intestinal tract is damaged due to various reasons, changes in the number and proportion of bacteria or spatial displacement result in bacterial translocation (BT), which ultimately leads to multiple organ dysfunction syndrome (MODS). Endogenous infections and endotoxemia caused by intestinal flora and endotoxin translocation are the origins of inflammatory responses, and the intestinal tract is the organ in which MODS both initiates and targets. Only by ensuring the integrity of the intestinal mucosal barrier can intestinal BT be effectively prevented. Elimination of the primary disease and maintaining blood and oxygen supply to the intestine is the most basic treatment. Early initiation of the intestinal tract, establishment of enteral nutrition, and selective digestive decontamination are also highly effective treatments. Early diagnosis, intervention, or prevention of BT may be a new avenue or important connection in the treatment of various diseases. The mechanism of BT, detection techniques, prevention and treatment, and its interaction with parenteral diseases were reviewed.
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Affiliation(s)
- Yan-Hua Wang
- State Key Laboratory of Veterinary Etiological Biology, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Sciences, Lanzhou, 730046, China.
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Identification of Dysfunctional Gut Microbiota Through Rectal Swab in Patients with Different Severity of Acute Pancreatitis. Dig Dis Sci 2020; 65:3223-3237. [PMID: 32076933 DOI: 10.1007/s10620-020-06061-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 01/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute pancreatitis (AP) has a wide spectrum of severity and can be associated with considerable morbidity and mortality. Whether gut microbiota dysbiosis is associated with AP severity remains obscure. AIMS We aim to investigate the differences in the alterations of gut microbiota in different grades of AP severity. METHODS We collected clinical information and rectal swab samples from 80 individuals. The gut microbiota was tested by 16S rRNA gene sequencing, gut microbiota species composition analysis, difference analysis, random forest model prediction analysis, and gut microbiota species correlation network analysis. RESULTS There was a different microbiota profile in different severity grades. Bacteroides, Escherichis-Shigella, and Enterococcus were dominant species in mild, moderately severe, and severe AP, respectively. Finegoldia was the most significantly increased and Blautia the most decreased species in mild AP. Anaerococcus was the most significantly increased and Eubacterium hallii the most decreased species in moderately severe AP. Enterococcus was the most significantly increased and Eubacterium hallii the most decreased species in severe AP. Finegoldia, Eubacterium_hallii, and Lachnospiraceae were potential diagnostic biomarkers for mild AP and Eubacterium_hallii and Anaerococcus for moderately severe AP. There was a positive interaction between Firmicutes and Bacteroidetes in mild AP. CONCLUSIONS The disturbed gut microbiota is different among grades of AP, suggesting their potential role in the progression of disease severity. There was a different microbiota profile in different severity grades. Bacteroides, Escherichis-Shigella, and Enterococcus were dominant gut microbiota species in MAP, MSAP, and SAP, respectively. Finegoldia was the most significantly increased and Blautia the most decreased gut microbiota species in MAP. Anaerococcus was the most significantly increased and Eubacterium hallii the most decreased species in MSAP. Enterococcus was the most significantly increased and Eubacterium hallii the most decreased species in SAP. Finegoldia, Eubacterium_hallii, and Lachnospiraceae were potential diagnostic biomarkers for MAP and Eubacterium_hallii and Anaerococcus for MSAP. There was a positive interaction between Firmicutes and Bacteroidetes in MAP.
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Heckler M, Hackert T, Hu K, Halloran CM, Büchler MW, Neoptolemos JP. Severe acute pancreatitis: surgical indications and treatment. Langenbecks Arch Surg 2020; 406:521-535. [PMID: 32910276 PMCID: PMC8106572 DOI: 10.1007/s00423-020-01944-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022]
Abstract
Background Acute pancreatitis (AP) is defined as an acute inflammatory attack of the pancreas of sudden onset. Around 25% of patients have either moderately severe or severe disease with a mortality rate of 15–20%. Purpose The aim of this article was to summarize the advances being made in the understanding of this disease and the important role of surgery. Results and conclusions An accurate diagnosis should be made a soon as possible, initiating resuscitation with large volume intravenous fluids and oxygen by mask. Predicted severe disease will require intensive monitoring. Most deaths within the first week are due to multi-organ failure; thus, these patients will require intensive therapy unit management. During the second phase of the disease, death is due to local complications arising from the pancreatic inflammation, requiring accurate identification to determine the correct form of treatment. Acute peripancreatic fluid collections arise < 4 weeks after onset of interstitial edematous pancreatitis, not requiring any treatment. Most pancreatic pseudocysts arise > 4 weeks and largely resolve on conservative management. Necrotizing pancreatitis causing acute necrotic collections and later walled-off necrosis will require treatment if symptomatic or infected. Initial endoscopic transgastric or percutaneous drainage will resolve less serious collections but necrosectomy using minimally invasive approaches will be needed for more serious collections. To prevent recurrent attacks of AP, causative factors need to be removed where possible such as cholecystectomy and cessation of alcohol. Future progress requires improved management of multi-organ failure and more effective minimally invasive techniques for the removal of necrosis.
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Affiliation(s)
- Max Heckler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany
| | - Kai Hu
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany
| | - Cristopher M Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany
| | - John P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany.
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Haney CM, Kowalewski KF, Schmidt MW, Koschny R, Felinska EA, Kalkum E, Probst P, Diener MK, Müller-Stich BP, Hackert T, Nickel F. Endoscopic versus surgical treatment for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials. Surg Endosc 2020; 34:2429-2444. [PMID: 32112252 PMCID: PMC7214487 DOI: 10.1007/s00464-020-07469-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/19/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare outcomes of endoscopic and surgical treatment for infected necrotizing pancreatitis (INP) based on results of randomized controlled trials (RCT). BACKGROUND Treatment of INP has changed in the last two decades with adoption of interventional, endoscopic and minimally invasive surgical procedures for drainage and necrosectomy. However, this relies mostly on observational studies. METHODS We performed a systematic review following Cochrane and PRISMA guidelines and AMSTAR-2 criteria and searched CENTRAL, Medline and Web of Science. Randomized controlled trails that compared an endoscopic treatment to a surgical treatment for patients with infected walled-off necrosis and included one of the main outcomes were eligible for inclusion. The main outcomes were mortality and new onset multiple organ failure. Prospero registration ID: CRD42019126033 RESULTS: Three RCTs with 190 patients were included. Intention to treat analysis showed no difference in mortality. However, patients in the endoscopic group had statistically significant lower odds of experiencing new onset multiple organ failure (odds ratio (OR) confidence interval [CI] 0.31 [0.10, 0.98]) and were statistically less likely to suffer from perforations of visceral organs or enterocutaneous fistulae (OR [CI] 0.31 [0.10, 0.93]), and pancreatic fistulae (OR [CI] 0.09 [0.03, 0.28]). Patients with endoscopic treatment had a statistically significant lower mean hospital stay (Mean difference [CI] - 7.86 days [- 14.49, - 1.22]). No differences in bleeding requiring intervention, incisional hernia, exocrine or endocrine insufficiency or ICU stay were apparent. Overall certainty of evidence was moderate. CONCLUSION There seem to be possible benefits of endoscopic treatment procedure. Given the heterogenous procedures in the surgical group as well as the low amount of randomized evidence, further studies are needed to evaluate the combination of different approaches and appropriate timepoints for interventions.
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Affiliation(s)
- C M Haney
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - K F Kowalewski
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - M W Schmidt
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - R Koschny
- Department of Gastroenterology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - E A Felinska
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - E Kalkum
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - P Probst
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - M K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - B P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - F Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Ausania F, Senra Del Río P, Borin A, Guzmán Suárez S, Rivera Irigoin R, Fort Martorell E, Concepción-Martín M, Del Val Antoñana A, Ferrández A, Grau García FJ, Ruiz Rebollo ML, Andreu EB, de-Madaria E. Factors associated with mortality in patients with infected pancreatic necrosis: the "surgery effect". Updates Surg 2020; 72:1097-1103. [PMID: 32306274 DOI: 10.1007/s13304-020-00764-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/10/2020] [Indexed: 11/26/2022]
Abstract
Severe acute pancreatitis complicated by infection is associated with high mortality. Invasive treatment is indicated in the presence of infected (suspected) pancreatic and/or peripancreatic necrosis (IPN) in the absence of response to intensive medical support. Step-up approach (SUA) has been demonstrated to lower complication rate compared to upfront open surgery. However, this approach has not been associated with lower mortality, and no factors have been studied that could help to identify the high risk patients. In this study, we aimed to analyse those factors associated with mortality following the invasive treatment of IPN, focusing on the role of surgical necrosectomy. A retrospective and observational study based on a multicentre prospective database was conducted. The database was coordinated by the Hospital General Universitario de Alicante, Spain and the Spanish Association of Pancreatology. Demographics, clinical data, and laboratory and imaging findings were collected. Atlanta 2012 criteria were considered to classify acute necrotizing pancreatitis and for the definition of IPN. Step-up approach was used in all centres with the intention of avoiding surgery whenever possible. Surgical necrosectomy was performed by open approach. From January 2013 to October 2014, a total of 1655 patients with the diagnosis of acute pancreatitis were included in our database. 1081 were recruited for the final analysis. Out of them, 205 (19%) were classified into acute necrotizing pancreatitis. 77 (8.3%) patients underwent invasive treatment of INP and were included in our study. Overall mortality was 29.9%. Upfront endoscopic or percutaneous drainage was performed in 60 (77.9%) patients and mortality was 26.6%. Out of 60, 22 (36.6%) patients subsequently received rescue surgery; mortality in rescue surgery group was 18.3%. Upfront surgery was carried out in 17 (22.1%) patients; mortality in this group was 41%. At univariate analysis, surgical necrosectomy, extrapancreatic infection, immunosuppression and de-novo haemodialysis were associated with mortality. At multivariate analysis, only surgical necrosectomy was significantly associated with mortality (p = 0.002 OR 3.89). Surgical approach for IPN is associated with high mortality rate. However, these data should be interpreted with caution, since we are not able to assess whether this occurs due to the need of surgery as the only resort when the other approaches are not feasible or fail.
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Affiliation(s)
| | | | - Alex Borin
- Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy.
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Tang Y, Peng Z, Liu H. Preoperative endoscopic transpapillary stenting: A solution to preventing and/or treating postsurgical external pancreatic fistula and infection in patients with infected necrotizing pancreatitis. Med Hypotheses 2020; 141:109733. [PMID: 32305814 DOI: 10.1016/j.mehy.2020.109733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 01/02/2023]
Abstract
Currently, open surgical necrosectomy is only performed when the step-up approach fails in patients with necrotizing pancreatitis. As a common complication after surgery, external pancreatic fistula often leads to a long hospital stay and increased expenditure. Current therapeutic strategies include conservative management; however, unresponsive patients with pancreatic leaks will frequently require interventions. Existing evidence indicates that endoscopic transpapillary stenting can shorten the duration of external pancreatic fistula; however, the length of conservative treatment in the early stage cannot be avoided. Therefore, endoscopic transpapillary stenting cannot play a decisive role in the treatment and prevention of postsurgical external pancreatic fistula. The authors propose that endoscopic transpapillary stenting before surgery, however, can be used to prevent and treat postsurgical external pancreatic fistula and complications caused by the prolonged maintenance of the drainage tube for abscesses, including retrograde infection, through its physiological drainage effect. This hypothesis has important clinical implications for the accelerated postoperative recovery of patients with necrotizing pancreatitis.
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Affiliation(s)
- Yongliang Tang
- Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Zuxiang Peng
- Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Hongming Liu
- Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, Chongqing, China.
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Therapeutic Effects of Apamin as a Bee Venom Component for Non-Neoplastic Disease. Toxins (Basel) 2020; 12:toxins12030195. [PMID: 32204567 PMCID: PMC7150898 DOI: 10.3390/toxins12030195] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 02/06/2023] Open
Abstract
Bee venom is a natural toxin produced by honeybees and plays an important role in defending bee colonies. Bee venom has several kinds of peptides, including melittin, apamin, adolapamine, and mast cell degranulation peptides. Apamin accounts for about 2%-3% dry weight of bee venom and is a peptide neurotoxin that contains 18 amino acid residues that are tightly crosslinked by two disulfide bonds. It is well known for its pharmacological functions, which irreversibly block Ca2+-activated K+ (SK) channels. Apamin regulates gene expression in various signal transduction pathways involved in cell development. The aim of this study was to review the current understanding of apamin in the treatment of apoptosis, fibrosis, and central nervous system diseases, which are the pathological processes of various diseases. Apamin's potential therapeutic and pharmacological applications are also discussed.
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Bang JY, Wilcox CM, Arnoletti JP, Varadarajulu S. Superiority of endoscopic interventions over minimally invasive surgery for infected necrotizing pancreatitis: meta-analysis of randomized trials. Dig Endosc 2020; 32:298-308. [PMID: 31220368 DOI: 10.1111/den.13470] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Infected necrotizing pancreatitis is a highly morbid disease managed by minimally invasive surgical (MIS) or endoscopy-based interventions. This meta-analysis compared the clinical outcomes of patients treated using either approach. METHODS MEDLINE and EMBASE databases were searched to identify all randomized trials that compared MIS and endoscopy-based interventions for treatment of infected necrotizing pancreatitis. Main outcome measure was to compare rates of complications or death during 6-month follow-up. RESULTS Three studies involving 184 patients met inclusion criteria. While there was no significant difference in mortality (14.5% vs. 16.1%, risk ratio [RR] = 1.02, P = 0.963), new onset multiple organ failure (5.2% vs. 19.7%, RR = 0.34, P = 0.045), enterocutaneous fistula/perforation (3.6% vs. 17.9%, RR = 0.34, P = 0.034) and pancreatic fistula (4.2% vs. 38.2%, RR = 0.13, P < 0.001) were significantly lower for endoscopic interventions compared to MIS. There was no significant difference in intraabdominal bleeding, endocrine or exocrine pancreatic insufficiency between cohorts. Length of hospital stay was significantly shorter for endoscopy (standardized mean difference, -0.41, P = 0.010). CONCLUSIONS An endoscopy-based treatment approach, as compared to minimally invasive surgery, significantly reduces complications in patients with infected necrotizing pancreatitis.
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Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, USA
| | - Charles Melbern Wilcox
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, USA
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Sundar V, Senthil Kumar KA, Manickam V, Ramasamy T. Current trends in pharmacological approaches for treatment and management of acute pancreatitis – a review. J Pharm Pharmacol 2020; 72:761-775. [DOI: 10.1111/jphp.13229] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 12/06/2019] [Indexed: 12/12/2022]
Abstract
Abstract
Objectives
Acute pancreatitis (AP) is an inimical disorder associated with overall mortality rates between 10-15%. It is a disorder of the exocrine pancreas which is characterized by local and systemic inflammatory responses primarily driven by oxidative stress and death of pancreatic acinar cells. The severity of AP ranges from mild pancreatic edema with complete recuperative possibilities to serious systemic inflammatory response resulting in peripancreatic/pancreatic necrosis, multiple organ failure, and death.
Key findings
We have retrieved the potential alternative approaches that are developed lately for efficacious treatment of AP from the currently available literature and recently reported experimental studies. This review summarizes the need for alternative approaches and combinatorial treatment strategies to deal with AP based on literature search using specific key words in PubMed and ScienceDirect databases.
Summary
Since AP results from perturbations of multiple signaling pathways, the so called “monotargeted smart drugs” of the past decade is highly unlikely to be effective. Also, the conventional treatment approaches were mainly involved in providing palliative care instead of curing the disease. Hence, many researchers are beginning to focus on developing alternate therapies to treat AP effectively. This review also summarizes the recent trends in the combinatorial approaches available for AP treatment.
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Affiliation(s)
- Vaishnavi Sundar
- School of Biosciences and Technology, Vellore Institute of Technology, Vellore, India
| | | | - Venkatraman Manickam
- School of Biosciences and Technology, Vellore Institute of Technology, Vellore, India
| | - Tamizhselvi Ramasamy
- School of Biosciences and Technology, Vellore Institute of Technology, Vellore, India
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50
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Thomas RM, Jobin C. Microbiota in pancreatic health and disease: the next frontier in microbiome research. Nat Rev Gastroenterol Hepatol 2020; 17:53-64. [PMID: 31811279 DOI: 10.1038/s41575-019-0242-7] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 12/12/2022]
Abstract
Diseases intrinsic to the pancreas such as pancreatitis, pancreatic cancer and type 1 diabetes mellitus impart substantial health and financial burdens on society but identification of novel mechanisms contributing to these pathologies are slow to emerge. A novel area of research suggests that pancreatic-specific disorders might be modulated by the gut microbiota, either through a local (direct pancreatic influence) or in a remote (nonpancreatic) fashion. In this Perspectives, we examine literature implicating microorganisms in diseases of the pancreas, specifically pancreatitis, type 1 diabetes mellitus and pancreatic ductal adenocarcinoma. We also discuss evidence of an inherent pancreatic microbiota and the influence of the intestinal microbiota as it relates to disease association and development. In doing so, we address pitfalls in the current literature and areas of investigation that are needed to advance a developing field of research that has clinical potential to reduce the societal burden of pancreatic diseases.
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Affiliation(s)
- Ryan M Thomas
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL, USA
| | - Christian Jobin
- Department of Medicine, Division of Gastroenterology, University of Florida College of Medicine, Gainesville, FL, USA.
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