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Reporting of acute pancreatitis by radiologists-time for a systematic change with structured reporting template. Abdom Radiol (NY) 2020; 45:1277-1289. [PMID: 32189022 PMCID: PMC7223113 DOI: 10.1007/s00261-020-02468-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Acute pancreatitis has a wide array of imaging presentations. Various classifications have been used in the past to standardize the terminology and reduce confusing and redundant terms. We aim to review the historical and current classifications of acute pancreatitis and propose a new reporting template which can improve communication between various medical teams by use of appropriate terminology and structured radiology template. The standardized reporting template not only conveys the most important imaging findings in a simplified yet comprehensive way but also allows structured data collection for future research and teaching purposes.
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Colvin SD, Smith EN, Morgan DE, Porter KK. Acute pancreatitis: an update on the revised Atlanta classification. Abdom Radiol (NY) 2020; 45:1222-1231. [PMID: 31494708 DOI: 10.1007/s00261-019-02214-w] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute pancreatitis (AP) is the most common gastrointestinal disease resulting in hospitalization in the United States with reports of over 270,000 hospitalizations and costs up to 2.6 billion dollars per year. AP is highly variable in disease course and outcome. Established in 1992, the original Atlanta classification system aimed to categorize the wide spectrum of AP by creating consensus-based terminology for AP types, severity, and complications. Though the original system standardized terminology, certain terms and definitions (i.e. pancreatic abscess) were unclear and often misused. The 2012 revised Atlanta classification (RAC) system updated terms, clarified definitions, and incorporated the medical community's improved understanding of the physiology of AP. The resulting RAC effectively defined the morphologic types of pancreatitis, provided a more standardized system for disease severity grading, further classified the local retroperitoneal complications, and established objective measures to describe this highly variable but common disease. This review provides an update on the recent literature evaluating the RAC, discusses both the strengths and shortcomings of the RAC system (including problematic interobserver agreement), and considers improvements for future classification systems.
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Affiliation(s)
| | - Elainea N Smith
- Department of Radiology, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL, 35294, USA
| | - Desiree E Morgan
- Department of Radiology, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL, 35294, USA
| | - Kristin K Porter
- Department of Radiology, University of Alabama at Birmingham, 619 19th Street South, Birmingham, AL, 35294, USA.
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Badat N, Millet I, Corno L, Khaled W, Boulay-Coletta I, Zins M. Revised Atlanta classification for CT pancreatic and peripancreatic collections in the first month of acute pancreatitis: interobserver agreement. Eur Radiol 2019; 29:2302-2310. [DOI: 10.1007/s00330-018-5906-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 10/17/2018] [Accepted: 11/22/2018] [Indexed: 02/07/2023]
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Describing Peripancreatic Collections According to the Revised Atlanta Classification of Acute Pancreatitis: An International Interobserver Agreement Study. Pancreas 2017; 46:850-857. [PMID: 28697123 DOI: 10.1097/mpa.0000000000000863] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Severe acute pancreatitis is associated with peripancreatic morphologic changes as seen on imaging. Uniform communication regarding these morphologic findings is crucial for accurate diagnosis and treatment. For the original 1992 Atlanta classification, interobserver agreement is poor. We hypothesized that for the revised Atlanta classification, interobserver agreement will be better. METHODS An international, interobserver agreement study was performed among expert and nonexpert radiologists (n = 14), surgeons (n = 15), and gastroenterologists (n = 8). Representative computed tomographies of all stages of acute pancreatitis were selected from 55 patients and were assessed according to the revised Atlanta classification. The interobserver agreement was calculated among all reviewers and subgroups, that is, expert and nonexpert reviewers; interobserver agreement was defined as poor (≤0.20), fair (0.21-0.40), moderate (0.41-0.60), good (0.61-0.80), or very good (0.81-1.00). RESULTS Interobserver agreement among all reviewers was good (0.75 [standard deviation, 0.21]) for describing the type of acute pancreatitis and good (0.62 [standard deviation, 0.19]) for the type of peripancreatic collection. Expert radiologists showed the best and nonexpert clinicians the lowest interobserver agreement. CONCLUSIONS Interobserver agreement was good for the revised Atlanta classification, supporting the importance for widespread adaption of this revised classification for clinical and research communications.
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Huang J, Qu HP, Zheng YF, Song XW, Li L, Xu ZW, Mao EQ, Chen EZ. The revised Atlanta criteria 2012 altered the classification, severity assessment and management of acute pancreatitis. Hepatobiliary Pancreat Dis Int 2016; 15:310-5. [PMID: 27298108 DOI: 10.1016/s1499-3872(15)60040-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Atlanta criteria for acute pancreatitis (AP) has been revised recently. This study was to evaluate its practical value in classification of AP, the severity assessment and management. METHODS The clinical features, severity classification, outcome and risk factors for mortality of 3212 AP patients who had been admitted in Ruijin Hospital from 2004 to 2011 were analyzed based on the revised Atlanta criteria (RAC) and the original Atlanta criteria (OAC). RESULTS Compared to the OAC group, the incidence of severe acute pancreatitis (SAP) was decreased by approximately one half (13.9% vs 28.2%) in the RAC group. The RAC presented a lower sensitivity but higher specificity, and its predictive value for severity and poor outcome was higher than those of the OAC. The proportion of SAP diagnosis and ICU admission in the early phase in the RAC group was significantly lower than that in the OAC group (P<0.05). Based on the RAC, the risk factors for death among SAP patients were older age, high CT severity index (CTSI), renal failure, cardiovascular failure, acute necrotic collection and walled-off necrosis. Compared to the OAC, the acute physiology and chronic health evaluation II (APACHE II) score, Ranson score, idiopathic etiology, respiratory failure and laparotomy debridement were not risk factors of death in contrast to walled-off necrosis. Interestingly, hypertriglyceridemia-related SAP had good outcomes in both groups. CONCLUSIONS The RAC showed a higher predictive value for severity and poorer outcome than the OAC. However, the RAC resulted in fewer ICU admissions in the early phase due to its lower sensitivity for diagnosis of SAP. Among SAP cases, older age, high CTSI, renal and cardiovascular failure, complications of acute necrotic collection and walled-off necrosis were independent risk factors for mortality.
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Affiliation(s)
- Jie Huang
- Department of Surgery and Department of Emergency, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China.
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Bollen TL. Acute pancreatitis: international classification and nomenclature. Clin Radiol 2015; 71:121-33. [PMID: 26602933 DOI: 10.1016/j.crad.2015.09.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 09/09/2015] [Accepted: 09/24/2015] [Indexed: 12/11/2022]
Abstract
The incidence of acute pancreatitis (AP) is increasing and it is associated with a major healthcare concern. New insights in the pathophysiology, better imaging techniques, and novel treatment options for complicated AP prompted the update of the 1992 Atlanta Classification. Updated nomenclature for pancreatic collections based on imaging criteria is proposed. Adoption of the newly Revised Classification of Acute Pancreatitis 2012 by radiologists should help standardise reports and facilitate accurate conveyance of relevant findings to referring physicians involved in the care of patients with AP. This review will clarify the nomenclature of pancreatic collections in the setting of AP.
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Affiliation(s)
- T L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, The Netherlands.
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Acute Pancreatitis: Revised Atlanta Classification and the Role of Cross-Sectional Imaging. AJR Am J Roentgenol 2015; 205:W32-41. [PMID: 26102416 DOI: 10.2214/ajr.14.14056] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The 2012 revision of the Atlanta Classification emphasizes accurate characterization of collections that complicate acute pancreatitis: acute peripancreatic fluid collections, pseudocysts, acute necrotic collections, and walled-off necroses. As a result, the role of imaging in the management of acute pancreatitis has substantially increased. CONCLUSION This article reviews the imaging findings associated with acute pancreatitis and its complications on cross-sectional imaging and discusses the role of imaging in light of this revision.
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Chen Y, Ke L, Tong Z, Li W, Li J. Association between severity and the determinant-based classification, Atlanta 2012 and Atlanta 1992, in acute pancreatitis: a clinical retrospective study. Medicine (Baltimore) 2015; 94:e638. [PMID: 25837754 PMCID: PMC4554029 DOI: 10.1097/md.0000000000000638] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Recently, the determinant-based classification (DBC) and the Atlanta 2012 have been proposed to provide a basis for study and treatment of acute pancreatitis (AP). The present study aimed to evaluate the association between severity and the DBC, the Atlanta 2012 and the Atlanta 1992, in AP. Patients admitted to our center with AP from January 2007 to July 2013 were reviewed retrospectively. Patients were assigned to severity categories for all the 3 classification systems. The primary outcomes include long-term clinical prognosis (mortality and length-of-hospital stay), major complications (intraabdominal hemorrhage, multiple-organ dysfunction, single organ failure [OF], and sepsis) and clinical interventions (surgical drainage, continuous renal replace therapy [CRRT] lasting time, and mechanical ventilation [MV] lasting time). The classification systems were validated and compared in terms of these abovementioned primary outcomes. A total of 395 patients were enrolled in this retrospective study with an overall 8.86% in-hospital mortality. Intraabdominal hemorrhage was present in 27 (6.84%) of the patients, multiple-organ dysfunction in 73(18.48%), single OF in 67 (16.96%), and sepsis in 73(18.48%). For each classification system, different categories regarding severity were associated with statistically different clinical mortality, major complications, and clinical interventions (P < 0.05). However, the Atlanta 2012 and the DBC performed better than the Atlanta 1992, and they were comparable in predicting mortality (area under curve [AUC] 0.899 and 0.955 vs 0.585, P < 0.05); intraabdominal hemorrhage (AUC 0.930 and 0.961 vs 0.583, P < 0.05), multiple-organ dysfunction (AUC 0.858 and 0.881 vs 0.595, P < 0.05), sepsis (AUC 0.826 and 0.879 vs 0.590, P < 0.05), and surgical drainage (AUC 0.900 and 0.847 vs 0.606, P < 0.05). For continuous variables, the Atlanta 2012 and the DBC were also better than the Atlanta 1992, and they were similar in predicting CRRT lasting time (Somer D 0.379 and 0.360 vs 0.210, P < 0.05) and MV lasting time (Somer D 0.344 and 0.336 vs 0.186, P < 0.05). All the 3 classification systems accurately classify the severity of AP. However, the Atlanta 2012 and the DBC performed better than the Atlanta 1992, and they were comparable in predicting long-term clinical prognosis, major complications, and clinical interventions.
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Affiliation(s)
- Yuhui Chen
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, People's Repubic of China
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9
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Visualization of the omental bursa and its spatial relationships to left subphrenic extraperitoneal spaces by the second Chinese Visible Human model. Surg Radiol Anat 2015; 37:473-81. [PMID: 25820977 PMCID: PMC4432027 DOI: 10.1007/s00276-015-1462-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 03/16/2015] [Indexed: 11/13/2022]
Abstract
Purpose In order to overcome the obstacle that detailed spatial relationships of the omental bursa to its related spaces cannot be displayed clearly by thick-slice sectional anatomical imaging and computed tomography, we designed a new approach to three-dimensional (3D) visualization of the omental bursa. Methods By Amira® software, we employed thin-slice cross-sectional images of the upper abdomen retrieved from second Chinese Visible Human datasets to display the spatial relationships of the omental bursa to its related spaces, especially to the left subphrenic extraperitoneal spaces. Moreover, these spatial relationships were presented on 3D sections reconstructed from second Chinese Visible Human images and computed tomography images. Results Of importance, the gastric bare area is located among the superior, inferior, and splenic recesses. The appearance of the foramen bursae omenti majoris is the only pathway communicating between the superior and inferior recesses of the omental bursa, and also is the anatomic landmark between the superior and inferior recesses. The splenic recess is surrounded from behind by the splenic bare area and the gastric bare area. Conclusion As one of the subphrenic spaces, the omental bursa with its related spaces was imaged three-dimensionally using a visualization technique. Familiarity with the anatomic location and spatial relationships of the omental bursa to its related spaces may be beneficial for the differential diagnosis and intervention, improving outcome. Electronic supplementary material The online version of this article (doi:10.1007/s00276-015-1462-3) contains supplementary material, which is available to authorized users.
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Bakker OJ, Issa Y, van Santvoort HC, Besselink MG, Schepers NJ, Bruno MJ, Boermeester MA, Gooszen HG. Treatment options for acute pancreatitis. Nat Rev Gastroenterol Hepatol 2014; 11:462-9. [PMID: 24662281 DOI: 10.1038/nrgastro.2014.39] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This Review covers the latest developments in the treatment of acute pancreatitis. The Atlanta Classification of acute pancreatitis has been revised, proposing several new terms and abandoning some of the old and confusing terminology. The 2012 Revised Atlanta Classification and the determinant-based classification aim to universally define the different local and systemic complications and predict outcome. The most important differences between these classifications are discussed. Several promising treatment options for the early management of acute pancreatitis have been tested, including the use of enteral nutrition and antibiotics as well as novel therapies such as haemofiltration and protease inhibitors. The results are summarized and the quality of evidence is discussed. Finally, new developments in the management of patients with infected pancreatic necrosis are addressed, including the use of the 'step-up approach' and results of minimally invasive necrosectomy.
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Affiliation(s)
- Olaf J Bakker
- Department of Surgery, Room G04.228, University Medical Center Utrecht Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, Netherlands
| | - Yama Issa
- Department of Surgery (Suite G4-136), Academic Medical Center, Meibergdreef 9, 1105 AZ, PO Box 22660, 1100 DD Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Room G04.228, University Medical Center Utrecht Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery (Suite G4-136), Academic Medical Center, Meibergdreef 9, 1105 AZ, PO Box 22660, 1100 DD Amsterdam, Netherlands
| | - Nicolien J Schepers
- Department of Gastroenterology &Hepatology, Erasmus Medical Center, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE Rotterdam, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology &Hepatology, Erasmus Medical Center, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE Rotterdam, Netherlands
| | - Marja A Boermeester
- Department of Surgery (Suite G4-136), Academic Medical Center, Meibergdreef 9, 1105 AZ, PO Box 22660, 1100 DD Amsterdam, Netherlands
| | - Hein G Gooszen
- Department of Operation Rooms/Evidence Based Surgery, Radboud University Medical Centre, Geert Grooteplein zuid 10, PO Box 9101, 6500 HB Nijmegen, Netherlands
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Classifications of acute pancreatitis: to Atlanta and beyond. Open Med (Wars) 2014. [DOI: 10.2478/s11536-013-0293-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AbstractUntil Atlanta Classification (AC) made in 1992, there was not any classification of acute pancreatitis (AP). Last twenty years AC let us compare results and papers. But the increasing understanding of the pathophysiology of AP, improvements in diagnostic methods and the development of minimally invasive tools for radiological, endoscopic and surgical management of local complications, several authors have called for the AC to be reviewed. Last months, two new classifications of AP have been published. We made a historical review of AC, the two new classifications and a comparison between them.
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Acevedo-Piedra NG, Moya-Hoyo N, Rey-Riveiro M, Gil S, Sempere L, Martínez J, Lluís F, Sánchez-Payá J, de-Madaria E. Validation of the determinant-based classification and revision of the Atlanta classification systems for acute pancreatitis. Clin Gastroenterol Hepatol 2014; 12:311-6. [PMID: 23958561 DOI: 10.1016/j.cgh.2013.07.042] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 06/25/2013] [Accepted: 07/11/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Two new classification systems for the severity of acute pancreatitis (AP) have been proposed, the determinant-based classification (DBC) and a revision of the Atlanta classification (RAC). Our aim was to validate and compare these classification systems. METHODS We analyzed data from adult patients with AP (543 episodes of AP in 459 patients) who were admitted to Hospital General Universitario de Alicante from December 2007 to February 2013. Imaging results were reviewed, and the classification systems were validated and compared in terms of outcomes. RESULTS Pancreatic necrosis was present in 66 of the patients (12%), peripancreatic necrosis in 109 (20%), walled-off necrosis in 61 (11%), acute peripancreatic fluid collections in 98 (18%), and pseudocysts in 19 (4%). Transient and persistent organ failures were present in 31 patients (6%) and 21 patients (4%), respectively. Sixteen patients (3%) died. On the basis of the DBC, 386 (71%), 131 (24%), 23 (4%), and 3 (0.6%) patients were determined to have mild, moderate, severe, or critical AP, respectively. On the basis of the RAC, 363 patients (67%), 160 patients (30%), and 20 patients (4%) were determined to have mild, moderately severe, or severe AP, respectively. The different categories of severity for each classification system were associated with statistically significant and clinically relevant differences in length of hospital stay, need for admission to the intensive care unit, nutritional support, invasive treatment, and in-hospital mortality. In comparing similar categories between the classification systems, no significant differences were found. CONCLUSION The DBC and the RAC accurately classify the severity of AP in subgroups of patients.
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Affiliation(s)
- Nelly G Acevedo-Piedra
- Unidad de Patología Pancreática, Hospital General Universitario de Alicante, Alicante, Spain
| | - Neftalí Moya-Hoyo
- Unidad de Patología Pancreática, Hospital General Universitario de Alicante, Alicante, Spain
| | - Mónica Rey-Riveiro
- Unidad de Patología Pancreática, Hospital General Universitario de Alicante, Alicante, Spain
| | - Santiago Gil
- Servicio de Radiología, Hospital General Universitario de Alicante, Alicante, Spain
| | - Laura Sempere
- Unidad de Patología Pancreática, Hospital General Universitario de Alicante, Alicante, Spain
| | - Juan Martínez
- Unidad de Patología Pancreática, Hospital General Universitario de Alicante, Alicante, Spain
| | - Félix Lluís
- Unidad de Patología Pancreática, Hospital General Universitario de Alicante, Alicante, Spain
| | - José Sánchez-Payá
- Servicio de Medicina Preventiva, Hospital General Universitario de Alicante, Alicante, Spain
| | - Enrique de-Madaria
- Unidad de Patología Pancreática, Hospital General Universitario de Alicante, Alicante, Spain.
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ISAJI S, TANEMURA A, AZUMI Y. Concept and definition of walled-off necrosis (WON) in acute pancreatitis. ACTA ACUST UNITED AC 2014. [DOI: 10.2958/suizo.29.202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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van den Heever M, Mittal A, Haydock M, Windsor J. The use of intelligent database systems in acute pancreatitis--a systematic review. Pancreatology 2013; 14:9-16. [PMID: 24555973 DOI: 10.1016/j.pan.2013.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 10/15/2013] [Accepted: 11/18/2013] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Acute pancreatitis (AP) is a complex disease with multiple aetiological factors, wide ranging severity, and multiple challenges to effective triage and management. Databases, data mining and machine learning algorithms (MLAs), including artificial neural networks (ANNs), may assist by storing and interpreting data from multiple sources, potentially improving clinical decision-making. AIMS 1) Identify database technologies used to store AP data, 2) collate and categorise variables stored in AP databases, 3) identify the MLA technologies, including ANNs, used to analyse AP data, and 4) identify clinical and non-clinical benefits and obstacles in establishing a national or international AP database. METHODS Comprehensive systematic search of online reference databases. The predetermined inclusion criteria were all papers discussing 1) databases, 2) data mining or 3) MLAs, pertaining to AP, independently assessed by two reviewers with conflicts resolved by a third author. RESULTS Forty-three papers were included. Three data mining technologies and five ANN methodologies were reported in the literature. There were 187 collected variables identified. ANNs increase accuracy of severity prediction, one study showed ANNs had a sensitivity of 0.89 and specificity of 0.96 six hours after admission--compare APACHE II (cutoff score ≥8) with 0.80 and 0.85 respectively. Problems with databases were incomplete data, lack of clinical data, diagnostic reliability and missing clinical data. CONCLUSION This is the first systematic review examining the use of databases, MLAs and ANNs in the management of AP. The clinical benefits these technologies have over current systems and other advantages to adopting them are identified.
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Affiliation(s)
| | - Anubhav Mittal
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Matthew Haydock
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - John Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand.
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Loizou L, Albiin N, Ansorge C, Andersson M, Segersvärd R, Leidner B, Sundin A, Lundell L, Kartalis N. Computed tomography staging of pancreatic cancer: a validation study addressing interobserver agreement. Pancreatology 2013; 13:570-5. [PMID: 24280571 DOI: 10.1016/j.pan.2013.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 09/29/2013] [Accepted: 09/30/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Ductal adenocarcinoma in the head of the pancreas (PDAC) is usually unresectable at the time of diagnosis due to the involvement of the peripancreatic vessels. Various preoperative classification algorithms have been developed to describe the relationship of the tumor to these vessels, but most of them lack a surgically based approach. We present a CT-based classification algorithm for PDAC based on surgical resectability principles with a focus on interobserver variability. METHODS Thirty patients with PDAC undergoing pancreaticoduodenectomy were examined by using a standard CT protocol. Nine radiologists, representing three different levels of expertise, evaluated the CT examinations and the tumors were classified into four categories (A-D) according to the proposed system. For the interobserver agreement, the Intraclass Correlation Coefficient (ICC) was estimated. RESULTS The overall ICC was 0.94 and the ICCs among the trainees, experienced radiologists, and experts were 0.85, 0.76, and 0.92, respectively. All tumors classified as category A1 showed no signs of vascular invasion at surgery. In category A2, 40% of the tumors had corresponding infiltration and required resection of the superior mesenteric vein/portal vein (SMV/PV). One of two tumors in category B2 and two of three in category C required SMV/PV resection. All six patients in category D had both arterial and venous involvement. CONCLUSION There is almost perfect agreement among radiologists with different levels of expertise in regards to the local staging of PDAC. For tumors in a more advanced preoperative category, an increased risk for vascular involvement was noticed at surgery.
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Affiliation(s)
- L Loizou
- Department of Clinical Science, Intervention and Technology at Karolinska Institutet, Division of Medical Imaging and Technology, 14186 Stockholm, Sweden; Department of Radiology, Karolinska University Hospital, Huddinge, 14186 Stockholm, Sweden
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Bollen TL. Imaging of acute pancreatitis: update of the revised Atlanta classification. Radiol Clin North Am 2012; 50:429-45. [PMID: 22560690 DOI: 10.1016/j.rcl.2012.03.015] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute pancreatitis is an acute inflammatory process of the pancreatic gland with increasing incidence worldwide. Usually the clinical presentation and course are mild, with an uneventful recovery. In 10% to 20% of patients, however, local and systemic complications develop, resulting in significant morbidity and mortality. In 1992, the Atlanta symposium provided definitions for acute pancreatitis and its severity. Insights into the pathophysiology of the disease, improved diagnostic imaging, and implementation of minimally invasive techniques have led to classification updates. This article reviews the cross-sectional imaging features of acute pancreatitis and presents proposed definitions of the revised Atlanta classification.
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Affiliation(s)
- Thomas L Bollen
- Department of Radiology, St Antonius Hospital, PO Box 2500, Koekoekslaan 1, 3430 EM Nieuwegein, The Netherlands.
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17
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Bollen TL. WITHDRAWN: Imaging of Acute Pancreatitis: Revised Atlanta Classification. Radiol Clin North Am 2012. [DOI: 10.1016/j.rcl.2012.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Sheu Y, Furlan A, Almusa O, Papachristou G, Bae KT. The revised Atlanta classification for acute pancreatitis: a CT imaging guide for radiologists. Emerg Radiol 2011; 19:237-43. [PMID: 22160496 DOI: 10.1007/s10140-011-1001-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 11/08/2011] [Indexed: 02/08/2023]
Abstract
Accurate diagnosis and description of the various findings in acute pancreatitis is important for treatment. The original Atlanta classification for acute pancreatitis sought to create a uniform system for classifying the severity of acute pancreatitis as well as common language to describe the various events that can occur in acute pancreatitis. The goal was to allow accurate communication between physicians using standardized language so correct treatment options could be used. Since that time, advances in the understanding of acute pancreatitis as well as improvements in both interventions and imaging have led to criticisms of the system and its abandonment by physicians. A 2007 revision of the Atlanta classifications sought to address many of these issues. This article will explain the changes to the Atlanta classification system and provide pictorial examples of the findings in acute pancreatitis as described by the Atlanta classification system.
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Affiliation(s)
- Y Sheu
- Department of Radiology, University of Pittsburgh, 200 Lothrop Street, 3950 Presby South Towers, Pittsburgh, PA 15213, USA.
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Andersson B, Andersson R, Ohlsson M, Nilsson J. Prediction of severe acute pancreatitis at admission to hospital using artificial neural networks. Pancreatology 2011; 11:328-35. [PMID: 21757970 DOI: 10.1159/000327903] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 03/25/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Artificial neural networks (ANNs) are non-linear pattern recognition techniques, which can be used as a tool in medical decision-making. The aim of this study was to construct and validate an ANN model for early prediction of the severity of acute pancreatitis (AP). METHODS Patients treated for AP from 2002 to 2005 (n = 139) and from 2007 to 2009 (n = 69) were analyzed to develop and validate the ANN model. Severe AP was defined according to the Atlanta criteria. RESULTS ANNs selected 6 of 23 potential risk variables as relevant for severity prediction, including duration of pain until arrival at the emergency department, creatinine, hemoglobin, alanine aminotransferase, heart rate, and white blood cell count. The discriminatory power for prediction of progression to a severe course, determined from the area under the receiver-operating characteristic curve, was 0.92 for the ANN model, 0.84 for the logistic regression model (p = 0.030), and 0.63 for the APACHE II score (p < 0.001). The numbers of correctly classified patients for a sensitivity of 50 and 75% were significantly higher for the ANN model than for logistic regression (p = 0.002) and APACHE II (p < 0.001). CONCLUSION The ANN model identified 6 risk variables available at the time of admission, including duration of pain, a finding not being presented as a risk factor before. The severity classification developed proved to be superior to APACHE II. and IAP.
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Abstract
Significant literature on the management of acute severe acute pancreatitis has emerged in recent years. The new information ranges from data on newer single or multiparameter severity assessment tools and classification systems to therapeutic modalities. However, a few basic issues-the ideal severity assessment modality, volume of intravenous fluids required in the first 48 to 72 h, and the role of prophylactic antibiotics-are still not clear and are subject to controversy. The International Working Group has devised the Revised Atlanta Classification, which will be published soon. This new classification is eagerly awaited worldwide, and hopefully clarifies many of the problems of the original Atlanta Classification. In this article, we discuss the developments that have arisen in the past 2 to 3 years concerning the classification, prognostication, and early management of severe acute pancreatitis.
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Affiliation(s)
- Rupjyoti Talukdar
- Miles and Shirley Fiterman Center for Digestive Diseases, 200 First Street SW, Mayo Clinic, Rochester, MN 55905, USA.
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Revising the Atlanta classification of acute pancreatitis: festina lente. J Gastrointest Surg 2010; 14:1474-5. [PMID: 20585993 DOI: 10.1007/s11605-010-1269-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Accepted: 03/09/2010] [Indexed: 01/31/2023]
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22
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de Vries Reilingh TS, Postma VA, Aufenacker TJ, Strobbe LJA, Rosman C. A Rare Cause of Acute Upper Gastrointestinal Hemorrhage. Case Rep Gastroenterol 2009; 3:400-403. [PMID: 21103261 PMCID: PMC2988937 DOI: 10.1159/000256908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Acute upper gastrointestinal tract hemorrhage represents a frequent morbidity which can be localized and treated endoscopically. When endoscopic treatment alone is failing, radiological or surgical treatment may be warranted. A case history will be presented regarding a rare cause of intestinal hemorrhage with an extraordinary course of illness.
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Bakker OJ, van Santvoort HC, Besselink MGH, van der Harst E, Hofker HS, Gooszen HG. Prevention, detection, and management of infected necrosis in severe acute pancreatitis. Curr Gastroenterol Rep 2009; 11:104-110. [PMID: 19281697 DOI: 10.1007/s11894-009-0017-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The management of infected peripancreatic or pancreatic necrosis in patients with severe pancreatitis has changed considerably in recent years. This review discusses the recent literature on prevention, detection, and management of infected necrosis. Though antibiotics, probiotics, and enteral nutrition have been tried to prevent infected necrosis, only enteral nutrition has consistently proven to be effective. Antibiotics and probiotics have not shown a consistent beneficial effect on outcome. Enteral nutrition reduced infectious complications and mortality in severe pancreatitis, compared with parenteral nutrition. The detection of infection of pancreatic necrosis is important for clinical decision making. Fine-needle aspiration may be used to confirm suspected infection, but if its results will not change clinical decisions, it should be omitted, as it may even introduce infection. Minimally invasive surgical, radiologic, or endoscopic intervention is increasingly being applied. In the absence of level 1 evidence, local expertise dictates which type of intervention is applied.
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Affiliation(s)
- Olaf J Bakker
- University Medical Center Utrecht, Department of Surgery, HP G04.228, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Abstract
BACKGROUND Acute pancreatitis has a variable natural history and in a proportion of patients is associated with severe complications and a significant risk of death. The various tools available for risk assessment in acute pancreatitis are reviewed. METHODS Relevant medical literature from PubMed, Ovid, Embase, Web of Science and The Cochrane Library websites to May 2008 was reviewed. RESULTS AND CONCLUSION Over the past 30 years several scoring systems have been developed to predict the severity of acute pancreatitis in the first 48-72 h. Biochemical and immunological markers, imaging modalities and novel predictive models may help identify patients at high risk of complications or death. Recently, there has been a recognition of the importance of the systemic inflammatory response syndrome and organ dysfunction.
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Affiliation(s)
- R Mofidi
- Department of Clinical and Surgical Sciences Surgery, University of Edinburgh, Edinburgh, UK
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25
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van Santvoort HC, Bollen TL, Besselink MG, Banks PA, Boermeester MA, van Eijck CH, Evans J, Freeny PC, Grenacher L, Hermans JJ, Horvath KD, Hough DM, Laméris JS, van Leeuwen MS, Mortele KJ, Neoptolemos JP, Sarr MG, Vege SS, Werner J, Gooszen HG. Describing peripancreatic collections in severe acute pancreatitis using morphologic terms: an international interobserver agreement study. Pancreatology 2008; 8:593-9. [PMID: 18849641 DOI: 10.1159/000161010] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Accepted: 07/16/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS The current terminology for describing peripancreatic collections in acute pancreatitis (AP) derived from the Atlanta Symposium (e.g. pseudocyst, pancreatic abscess) has shown a very poor interobserver agreement, creating the potential for patient mismanagement. A study was undertaken to determine the interobserver agreement for a new set of morphologic terms to describe peripancreatic collections in AP. METHODS An international, interobserver agreement study was performed: 7 gastrointestinal surgeons, 2 gastroenterologists and 8 radiologists in 3 US and 5 European tertiary referral hospitals independently evaluated 55 computed tomography (CT) scans of patients with predicted severe AP. The percentage agreement [median, interquartile range (IQR)] for 9 clinically relevant morphologic terms was calculated among all reviewers, and separately among radiologists and clinicians. The percentage agreement was defined as poor (<0.50), moderate (0.51-0.70), good (0.71-0.90), and excellent (0.91-1.00). RESULTS Overall agreement was good to excellent for the terms collection (percentage agreement = 1; IQR 0.68-1), relation with pancreas (1; 0.68-1), content (0.88; 0.87-1), shape (1; 0.78-1), mass effect (0.78; 0.62-1), loculated gas bubbles (1; 1-1), and air-fluid levels (1; 1-1). Overall agreement was moderate for extent of pancreatic nonenhancement (0.60; 0.46-0.88) and encapsulation (0.56; 0.48-0.69). The percentage agreement was greater among radiologists than clinicians for extent of pancreatic nonenhancement (0.75 vs. 0.57, p = 0.008), encapsulation (0.67 vs. 0.46, p = 0.001), and content (1 vs. 0.78, p = 0.008). CONCLUSION Interobserver agreement for the new set of morphologic terms to describe peripancreatic collections in AP is good to excellent. Therefore, we recommend that current clinically based definitions for CT findings in AP (e.g. pancreatic abscess) should no longer be used.
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Morgan DE. Imaging of acute pancreatitis and its complications. Clin Gastroenterol Hepatol 2008; 6:1077-85. [PMID: 18928934 DOI: 10.1016/j.cgh.2008.07.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Revised: 07/16/2008] [Accepted: 07/19/2008] [Indexed: 02/07/2023]
Abstract
Patients with acute pancreatitis may present with mild or severe disease, the latter comprising a minority of cases but accounting for most of the morbidity and mortality associated with this disease. Contrast-enhanced computed tomography is the mainstay of imaging patients with acute pancreatitis and is widely used in both the community and academic settings. A variety of retroperitoneal morphologic changes are readily depicted, and the correct assessment of these abnormalities is imperative for management. The purpose of this review is to describe the imaging evaluation of patients with acute pancreatitis by using the 1992 Atlanta Symposium classification and definitions to describe local complications depicted on contrast-enhanced computed tomography. Correlation with the proposed revision of Atlanta Symposium definitions set forth by the Acute Pancreatitis Working Group will be discussed.
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Affiliation(s)
- Desiree E Morgan
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama 35233, USA.
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Takahashi N, Papachristou GI, Schmit GD, Chahal P, LeRoy AJ, Sarr MG, Vege SS, Mandrekar JN, Baron TH. CT findings of walled-off pancreatic necrosis (WOPN): differentiation from pseudocyst and prediction of outcome after endoscopic therapy. Eur Radiol 2008; 18:2522-9. [PMID: 18563416 DOI: 10.1007/s00330-008-1039-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Accepted: 04/06/2008] [Indexed: 12/11/2022]
Abstract
Computed tomography (CT) findings that may differentiate walled-off pancreatic necrosis (WOPN) from pancreatic pseudocyst were investigated. CT examinations performed before endoscopic therapy of pancreatic fluid collection (PFC) in 73 patients (45 WOPN, 28 pseudocysts) were evaluated retrospectively by two radiologists. PFC was evaluated for size, extension to paracolic space, characteristics of wall and internal structure. The pancreas was evaluated for deformity or discontinuity, and pancreatic duct dilation. CT findings that were associated with WOPN or pseudocyst were identified. CT score (number of CT findings associated with WOPN minus number of findings associated with pseudocyst) was calculated for each PFC. PFC was categorized as WOPN or pseudocyst using a CT score threshold. Larger size, extension to paracolic space, irregular wall definition, presence of fat attenuation debris in PFC, pancreatic deformity or discontinuity (P < 0.05-0.0001) were findings associated with WOPN. Presence of pancreatic duct dilation was associated with pseudocyst. Using a CT score of 2 or higher as a threshold, CT differentiated WOPN from pseudocyst with an accuracy of 79.5-83.6%. Thus, CT can differentiate WOPN from pseudocysts.
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Affiliation(s)
- Naoki Takahashi
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN, USA.
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Schrover IM, Weusten BLAM, Besselink MGH, Bollen TL, van Ramshorst B, Timmer R. EUS-guided endoscopic transgastric necrosectomy in patients with infected necrosis in acute pancreatitis. Pancreatology 2008; 8:271-6. [PMID: 18497540 DOI: 10.1159/000134275] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Accepted: 01/15/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Infected pancreatic and peripancreatic necrosis in acute pancreatitis is potentially lethal, with mortality rates up to 35%. Therefore, there is growing interest in minimally invasive treatment options, such as (EUS-guided) endoscopic transgastric necrosectomy. METHODS Retrospective cohort study on EUS-guided endoscopic transgastric necrosectomy in patients with infected necrosis in acute pancreatitis. RESULTS 8 patients (age 38-75, mean 50 years) with documented infected peripancreatic or pancreatic necrosis were included. Median time to first intervention was 33 days (range 17-62) after onset of symptoms. At the time of first intervention 2 patients had organ failure. All patients were managed on the patient ward. Initial endoscopic drainage was successful in all patients, a median of 4 (range 2-6) subsequent endoscopic necrosectomies were needed to remove all necrotic tissue. Two patients needed additional surgical intervention because of pneumoperitoneum (n = 1) and insufficient endoscopic drainage (n = 1). Six patients recovered, with 1 mild relapse during follow-up (median 12, range 8-60 months). One patient died. CONCLUSION EUS-guided endoscopic transgastric necrosectomy of infected necrosis in acute pancreatitis appears to be a feasible and relatively safe treatment option in patients who are not critically ill. Further randomized comparison with the current 'gold standard' is warranted to determine the place of this treatment modality.
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Affiliation(s)
- Ilse M Schrover
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, The Netherlands
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Bollen TL, van Santvoort HC, Besselink MG, van Leeuwen MS, Horvath KD, Freeny PC, Gooszen HG. The Atlanta Classification of acute pancreatitis revisited. Br J Surg 2008; 95:6-21. [PMID: 17985333 DOI: 10.1002/bjs.6010] [Citation(s) in RCA: 190] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In a complex disease such as acute pancreatitis, correct terminology and clear definitions are important. The clinically based Atlanta Classification was formulated in 1992, but in recent years it has been increasingly criticized. No formal evaluation of the use of the Atlanta definitions in the literature has ever been performed. METHODS A Medline literature search sought studies published after 1993. Guidelines, review articles and their cross-references were reviewed to assess whether the Atlanta or alternative definitions were used. RESULTS A total of 447 articles was assessed, including 12 guidelines and 82 reviews. Alternative definitions of predicted severity of acute pancreatitis, actual severity and organ failure were used in more than half of the studies. There was a large variation in the interpretation of the Atlanta definitions of local complications, especially relating to the content of peripancreatic collections. CONCLUSION The Atlanta definitions for acute pancreatitis are often used inappropriately, and alternative definitions are frequently applied. Such lack of consensus illustrates the need for a revision of the Atlanta Classification.
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Affiliation(s)
- T L Bollen
- Department of Radiology, St Antonius Hospital Nieuwegein, The Netherlands
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30
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Marshall JC. Acute Pancreatitis. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50080-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Bollen TL, Besselink MGH, van Santvoort HC, Gooszen HG, van Leeuwen MS. Toward an update of the atlanta classification on acute pancreatitis: review of new and abandoned terms. Pancreas 2007; 35:107-13. [PMID: 17632315 DOI: 10.1097/mpa.0b013e31804fa189] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The 1992 Atlanta classification is a clinically based classification system that defines the severity and complications of acute pancreatitis. The purpose of this review was to assess whether the terms abandoned by the Atlanta classification are really discarded in the literature. The second objective was to review what new terms have appeared in the literature since the Atlanta symposium. METHODS We followed a Medline search strategy in review and guideline articles after the publication of the Atlanta classification. This search included the abandoned terms: "phlegmon," "infected pseudocyst," "hemorrhagic pancreatitis," and "persistent pancreatitis." RESULTS A total of 239 publications were reviewed, including 10 guideline articles and 42 reviews. The abandoned terms "hemorrhagic pancreatitis" and "persistent pancreatitis" are hardly encountered, in contrast, both "infected pseudocyst" and "phlegmon" are frequently used, and several authors question their abandonment. New terminology in acute pancreatitis consists of "organized pancreatic necrosis," "necroma," "extrapancreatic necrosis," and "central gland necrosis." CONCLUSIONS This review demonstrates that the Atlanta classification is still not universally accepted. Several abandoned terms are frequently used, and new terms have emerged that describe manifestations in acute pancreatitis that were not specifically addressed during the Atlanta symposium.
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Affiliation(s)
- Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
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Besselink MGH, van Santvoort HC, Witteman BJ, Gooszen HG. Management of severe acute pancreatitis: it's all about timing. Curr Opin Crit Care 2007; 13:200-6. [PMID: 17327743 DOI: 10.1097/mcc.0b013e328015b8af] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW This study provides an update on the treatment of severe acute pancreatitis (SAP) with emphasis on nutrition, infection-prophylaxis, biliary pancreatitis, surgical intervention and new randomized controlled trials. RECENT FINDINGS The most relevant new insights are: (i) early enteral nutrition in SAP is not only capable of reducing infectious complications but may also reduce mortality; (ii) there is increasing evidence that antibiotic-prophylaxis is not capable of preventing infectious complications in SAP; (iii) probiotic-prophylaxis is being considered as an alternative with promising experimental results; (iv) in biliary pancreatitis, early endoscopic retrograde cholangiography with sphincterotomy (within 48 h) is beneficial in case of ampullary obstruction, although it may be withheld in the event of negative endoscopic ultrasound; (v) surgical intervention for infected (peri-)pancreatic necrosis is increasingly being postponed; (vi) minimally invasive strategies are being considered as a full alternative for necrosectomy by laparotomy in infected (peri-)pancreatic necrosis; (vii) the Atlanta classification should no longer be used to describe computed tomography findings in acute pancreatitis; and (viii) only five randomized controlled trials of patients with acute pancreatitis are currently registered in the international trial registries. SUMMARY Timing of intervention is becoming increasingly important in SAP management.
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Affiliation(s)
- Marc G H Besselink
- Department of Surgery, University Medical Center Utrecht, The Netherlands.
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