Management of severe acute pancreatitis: it's all about timing

Network pharmacology-based investigation and experimental validation of the therapeutic potential and molecular mechanism of Danshen Chuanxiongqin injection in acute pancreatitis

BACKGROUND

Danshen Chuanxiong Injection (DCI) has demonstrated significant clinical efficacy in the treatment of acute pancreatitis (AP); however, the precise molecular mechanisms underlying its therapeutic effects remain incompletely understood.

OBJECTIVE

In this study, we employed network pharmacology analysis to comprehensively investigate the active components, potential targets, and signaling pathways involved in DCI-mediated treatment of AP.

METHODS

We utilized the mouse pancreatic acinar cell line 266-6 to establish an cholecystokinin (CCK)-induced AP cell injury model and evaluated cell viability using the Cell counting kit-8 assay. Western blotting and quantitative PCR were employed to determine the expression levels of key target proteins and genes.

RESULTS

Network pharmacology analysis identified a total of 144 active components and 430 potential targets within DCI. By integrating data from public databases, we identified 762 AP-related genes. Among these, we identified 93 potential targets that may be involved in the therapeutic effects of DCI for AP. These targets were significantly enriched in biological processes such as oxidative stress, regulation of cytokine production, leukocyte migration, and the TNF signaling pathway. Molecular docking studies revealed a high binding affinity between the active components and the key targets AKT1 and NFKBA, indicative of potential interaction. Additionally, CCK-induced acinar cell injury led to upregulation of AKT1, NFKBA, and P53 proteins, as well as TNF, IL6, and MMP9 genes. Conversely, treatment with DCI dose-dependently attenuated CCK-induced acinar cell injury and restored the expression levels of the aforementioned proteins and genes.

CONCLUSION

Overall, this study provides a comprehensive understanding of the molecular mechanisms underlying the therapeutic effects of DCI in the treatment of AP. Our findings confirm the protective effect of DCI against CCK-induced acinar cell injury and its regulation of key targets.

Elucidating the Mechanism of Action of Salvia miltiorrhiza for the Treatment of Acute Pancreatitis Based on Network Pharmacology and Molecular Docking Technology

Using network pharmacology and molecular docking, this study investigated the molecular mechanisms by which the active components in Salvia miltiorrhiza can alleviate acute pancreatitis. Initially, the active components of Salvia miltiorrhiza and the targets collected from the GeneCards database were screened based on the platform of systematic pharmacology analysis of traditional Chinese medicine. Subsequently, the active components were intersected with the disease targets. Also, interactions among the targets were computed using the STRING database. Biological function and pathway enrichment were analyzed using the Cluster Profiler package in the R software. Protein-protein interaction and component target pathway network were constructed using the Cytoscape software. Ultimately, the key targets and their corresponding components in the network were verified using the AutoDock Vina software. The results showed Salvia miltiorrhiza had 111 targets for acute pancreatitis. The biological process (BP) analysis showed that the active components of Salvia miltiorrhiza induced a drug response, positive regulation of transcription by RNA polymerase II promoter, signal transduction, positive regulation of cell proliferation, and negative regulation of apoptosis. Furthermore, the KEGG enrichment analysis screened 118 (P < 0.05) signaling pathways, such as the pathways related to cancer, neuroactive ligand-receptor interaction, PI3K-Akt signaling pathway, and cAMP signaling pathway, to name a few. Finally, molecular docking showed that the active components of Salvia miltiorrhiza had a good binding affinity with their corresponding target proteins. Through network pharmacology, this study predicted the potential pharmacodynamic material basis and the mechanisms by which Salvia miltiorrhiza can treat acute pancreatitis. Moreover, this study provided a scientific basis for mining the pharmacodynamic components of Salvia miltiorrhiza and expanding the scope of its clinical use.

The role of endoscopic therapy in the minimally invasive management of pancreatic necrosis

Pancreatic necrosis is among the most frequently encountered local complications of acute pancreatitis and associates with severe disease. Infected pancreatic necrosis further enhances the risk for morbidity and mortality. Pancreatic fluid collections that result from pancreatic necrosis evolve from acute necrotic collections to walled off necrosis and are defined by their distinct characteristics on cross sectional imaging. A variety of interventions spanning multiple disciplines are available for the drainage and debridement of pancreatic necrosis. Prospective, randomized trials have identified management strategies that incorporate minimally invasive interventions as having the best outcomes for patients with symptomatic pancreatic necrosis. The scientific literature has confidently positioned endoscopic drainage and necrosectomy among the most effective interventions for patients with symptomatic walled off necrosis. Innovations such as the use of metallic stents, chemical debridement and multiple modalities for drainage of pancreatic necrosis show promise in improving outcomes for patients managed with endoscopic interventions.

Apigenin Exerts Anti-inflammatory Effects in an Experimental Model of Acute Pancreatitis by Down-regulating TNF-α

BACKGROUND/AIM

This study investigated the anti-inflammatory effect of apigenin in an experimental model of acute pancreatitis. Inflammatory response was reflected by tissue expression of the cytokine TNF-α coupled with histological examination.

MATERIALS AND METHODS

Wistar rats were divided into three groups: Sham-group animals underwent laparotomy only, without any other interventions. Control-group animals underwent laparotomy and bilio-pancreatic duct ligation to induce pancreatitis without apigenin administration. Apigenin group animals were further treated with apigenin. Euthanasia was performed at 6, 12, 24, 48 and 72 h post-operatively.

RESULTS

Over-expression of TNF-α in relation to postoperative time was observed in the control group (p<0.001). In the apigenin group, under-expression of TNF-α in relation to postoperative time was observed (p<0.013). At 72 h, apigenin reduced pancreatic TNF-α expression and prevented pancreatic necrosis.

CONCLUSION

Apigenin slows progression and reduces severity of acute pancreatitis. Apigenin may serve as an adjunct to a more successful therapeutic strategy in acute pancreatitis.

Application of semi-automated ultrasonography on nutritional support for severe acute pancreatitis

OBJECTIVE

To evaluate the application value of semi-automated ultrasound on the guidance of nasogastrojejunal tube replacement for patients with acute severe pancreatitis (ASP), as well as the value of the nutritional support for standardized treatment in clinical practice.

METHODS

The retrospective research was performed in our hospital, and 34 patients suffering from ASP were enrolled into this study. All these identified participants ever received CT scans in order to make definitive diagnoses. Following, these patients received semi-automated ultrasound examinations within 1 days after their onset, in order to provide enteral nutrititon treatment via nasogastrojejunal tube, or freehand nasogastrojejunal tube replacement. In terms of statistical analysis, the application value of semi-automated ultrasound guidance on nasogastrojejunal tube replacement was evaluated, and was compared with tube replacement of no guidance. After cathetering, the additional enteral nutrition was provided, and its therapeutic effect on SAP was analyzed in further.

RESULTS

A total of 34 patients with pancreatitis were identified in this research, 29 cases with necrosis of pancreas parenchyma. After further examinations, 32 cases were SAP, 2 cases were mild acute pancreatitis. When the firm diagnosis was made, additional enteral nutrition (EN) was given, all the patient conditions appeared good, and they all were satisfied with this kind of nutritional support. According to our clinical experience, when there was 200-250 ml liquid in the stomach, the successful rate of intubation appeared higher. Additionally, the comparison between ultrasound-guided and freehand nasogastrojejunal tube replacement was made. According to the statistical results, in terms of the utilization ratio of nutritional support, it was better in ultrasound-guided group, when compared with it in freehand group, within 1 day, after 3 days and after 7 days (7/20 versus 2/14; P < 0.05; 14/20 versus 6/14; P < 0.05; 20/20 versus 12/14; P < 0.05). Besides, the complications caused by cathetering between two groups was not statistically different (P > 0.05).

CONCLUSIONS

It can be indicated that semi-automated ultrasound guidance is a reliable method for nasogastrojejunal tube replacement, and should be substituted for no guidance of cathetering. In terms of therapeutic effect of EN, additional nutritional support contributed to significantly improve the prognosis of SAP patients, and should be widely recommended in clinical practice. Surely, this conclusion should be evaluated in further, by means of randomized controlled trials and economic evaluation.

High versus low energy administration in the early phase of acute pancreatitis (GOULASH trial): protocol of a multicentre randomised double-blind clinical trial

INTRODUCTION

Acute pancreatitis (AP) is an inflammatory disease with no specific treatment. Mitochondrial injury followed by ATP depletion in both acinar and ductal cells is a recently discovered early event in its pathogenesis. Importantly, preclinical research has shown that intracellular ATP delivery restores the physiological function of the cells and protects from cell injury, suggesting that restoration of energy levels in the pancreas is therapeutically beneficial. Despite several high quality experimental observations in this area, no randomised trials have been conducted to date to address the requirements for energy intake in the early phase of AP.

METHODS/DESIGN

This is a randomised controlled two-arm double-blind multicentre trial. Patients with AP will be randomly assigned to groups A (30 kcal/kg/day energy administration starting within 24 hours of hospital admission) or B (low energy administration during the first 72 hours of hospital admission). Energy will be delivered by nasoenteric tube feeding with additional intravenous glucose supplementation or total parenteral nutrition if necessary. A combination of multiorgan failure for more than 48 hours and mortality is defined as the primary endpoint, whereas several secondary endpoints such as length of hospitalisation or pain will be determined to elucidate more detailed differences between the groups. The general feasibility, safety and quality checks required for high quality evidence will be adhered to.

ETHICS AND DISSEMINATION

The study has been approved by the relevant organisation, the Scientific and Research Ethics Committee of the Hungarian Medical Research Council (55961-2/2016/EKU). This study will provide evidence as to whether early high energy nutritional support is beneficial in the clinical management of AP. The results of this trial will be published in an open access way and disseminated among medical doctors.

TRIAL REGISTRATION

The trial has been registered at the ISRCTN (ISRTCN 63827758).

Management of Severe Sepsis of Abdominal Origin

Severe sepsis is a life-threatening condition that may occur as a sequela of intra-abdominal infections (IAIs) of all types. Diagnosis of IAIs is predicated upon the combination of physical examination and imaging techniques. Diffuse peritonitis usually requires urgent surgical intervention. In the absence of diffuse peritonitis, abdominal computed tomography remains the most useful test for the diagnosis of IAIs, and is essential to both guide therapeutic interventions and evaluate suspected treatment failure in the critically ill patient. Parameters most consistently associated with poor outcomes in patients with IAIs include increased illness severity, failed source control, inadequate empiric antimicrobial therapy, and healthcare-acquired, as opposed to community-acquired infection. Whereas community-acquired IAI is characterized predominantly by enteric gram-negative bacilli and anaerobes that are susceptible to narrow-spectrum agents, healthcare-acquired IAI (e.g., anastomotic dehiscence, postoperative organ-space surgical site infection) frequently involves at least one multi-drug resistant pathogen, necessitating broad-spectrum therapy guided by both culture results and local antibiograms. The cornerstone of effective treatment for abdominal sepsis is early and adequate source control, which is supplemented by antibiotic therapy, restoration of a functional gastrointestinal tract (if possible), and support of organ dysfunction. Furthermore, mitigation of deranged immune and coagulation responses via therapy with recombinant human activated protein C may improve survival significantly in severe cases complicated by septic shock and multiple organ dysfunction syndrome.

Thoracic epidural analgesia: a new approach for the treatment of acute pancreatitis?

This review article analyzes, through a nonsystematic approach, the pathophysiology of acute pancreatitis (AP) with a focus on the effects of thoracic epidural analgesia (TEA) on the disease. The benefit-risk balance is also discussed. AP has an overall mortality of 1 %, increasing to 30 % in its severe form. The systemic inflammation induces a strong activation of the sympathetic system, with a decrease in the blood flow supply to the gastrointestinal system that can lead to the development of pancreatic necrosis. The current treatment for severe AP is symptomatic and tries to correct the systemic inflammatory response syndrome or the multiorgan dysfunction. Besides the removal of gallstones in biliary pancreatitis, no satisfactory causal treatment exists. TEA is widely used, mainly for its analgesic effect. TEA also induces a targeted sympathectomy in the anesthetized region, which results in splanchnic vasodilatation and an improvement in local microcirculation. Increasing evidence shows benefits of TEA in animal AP: improved splanchnic and pancreatic perfusion, improved pancreatic microcirculation, reduced liver damage, and significantly reduced mortality. Until now, only few clinical studies have been performed on the use of TEA during AP with few available data regarding the effect of TEA on the splanchnic perfusion. Increasing evidence suggests that TEA is a safe procedure and could appear as a new treatment approach for human AP, based on the significant benefits observed in animal studies and safety of use for human. Further clinical studies are required to confirm the clinical benefits observed in animal studies.

Multidetector CT in emergency radiology: acute and generalized non-traumatic abdominal pain

Multidetector CT (MDCT) is an imaging technique that provides otherwise unobtainable information in the diagnostic work-up of patients presenting with acute abdominal pain. A correct working diagnosis depends essentially on understanding the individual patient's clinical data and laboratory findings. In haemodynamically stable patients with acute severe and generalized abdominal pain, MDCT is now the preferred imaging test and gives invaluable diagnostic information, also in unstable patients after stabilization. In this descriptive review, we focus our attention on acute, severe and generalized or undifferentiated non-traumatic abdominal pain. The main differential diagnoses are acute pancreatitis, gastrointestinal perforation, ruptured abdominal aneurysm and acute mesenteric ischaemia. We will provide radiologist readers with a technical guide to optimize MDCT imaging protocols and list the major CT signs essential to reach a correct diagnosis and guide the best treatment.

The role of antimicrobial therapy in severe acute pancreatitis

The role of antimicrobial therapy in patients with severe acute pancreatitis is to treat secondary pancreatic infections to prevent systemic sepsis and death. Infected pancreatic necrosis is diagnosed using image-directed fine needle aspiration with culture and Gram's stain. Prophylactic antibiotics have not proven efficacious, while the precise timely detection of secondary pancreatic infections is often elusive. A high clinical index of suspicion should prompt the empiric initiation of antimicrobial therapy until culture results are available. Positive cultures should guide antimicrobial therapy, and for infected pancreatic necrosis, antibiotics should be used in conjunction with interventional techniques for source control.

Surgical indications in acute pancreatitis

PURPOSE OF REVIEW

This review provides an update on the surgical management of acute pancreatitis, with a focus on evidence accumulated over the past year regarding the optimal approach to pancreatic debridement in the critically ill patient.

RECENT FINDINGS

Infected pancreatic necrosis remains the primary indication for surgery in patients with acute pancreatitis. Up to a quarter of patients with acute pancreatitis develop early bacteremia and pneumonia, and assessment of patients for surgery should include a thorough search for nonpancreatic sources of infection. Retroperitoneal, percutaneous and endoscopic approaches to pancreatic debridement can be used with success in appropriately selected critically ill patients. All minimally invasive approaches to necrosectomy are evolving, and there is currently insufficient evidence to advocate one approach over another. Management of patients with acute pancreatitis at high-volume centers appears to be associated with a survival benefit.

SUMMARY

The existing evidence demonstrates that control of infected pancreatic necrosis without laparotomy is possible with appropriate patient selection. Evidence regarding minimally invasive approaches to pancreatic debridement remains of limited quality.

The impact of early goal-directed fluid management on survival in an experimental model of severe acute pancreatitis

PURPOSE

Severe acute pancreatitis (SAP) remains a life-threatening disease with classic etiology of systemic inflammatory response and mortality between 30 and 50 %. The aim of the present study is to compare two different treatment strategies of goal-directed hemodynamic management and evaluate their impact on survival, microcirculation, tissue oxygenation, and histopathologic damage in acute pancreatitis in a prospective animal study.

METHODS

Thirty-four domestic pigs were randomly assigned to two different treatment groups. After induction of acute pancreatitis, in group 1 volume administration was guided by central venous pressure (CVP >12 mmHg) and mean arterial pressure (MAP). In group 2, hemodynamic management was guided primarily by left-ventricular stroke volume variation (SVV <10 %), MAP, and cardiac output (CO). Treatment according to randomization was performed for 6 h, and tissue oxygen tension in the pancreas and pancreatic microcirculation were evaluated. Thereafter, animals were observed for 7 days and then sacrificed. Standardized tissue specimens were taken post mortem, and histopathologic scoring was performed.

RESULTS

Survival after 7 days was 29.4 % in group 2 versus 11.8 % in group 1 (p < 0.05). Pancreatic oxygen tension (138.0 ± 89.5 mmHg versus 71.1 ± 35.3 mmHg; p < 0.05) and pancreatic microcirculation (1,209.9 ± 630 AU versus 732 ± 315 AU; p < 0.05) were significantly higher in group 2. Significantly less histopathologic damage within the pancreas could be analyzed post mortem in group 2.

CONCLUSIONS

Goal-directed hemodynamic management guided by stroke volume variation led to improved survival, tissue oxygenation, and microcirculatory perfusion, as well as less histopathologic damage in an animal model of severe acute pancreatitis.

EUS finding of geographic hyperechoic area is an early predictor for severe acute pancreatitis

BACKGROUND/OBJECTIVES

Endoscopic ultrasonography (EUS) is an accurate imaging modality for delineating pancreatobiliary structures, however, its clinical application of acute pancreatitis (AP) is limited. Therefore, we sought to characterize the typical EUS features of AP and to determine whether early EUS findings may have prognostic significance.

METHODS

Between March 2008 and October 2010, 90 patients with AP and 90 patients without pancreatic disease who underwent EUS were enrolled. An EUS examination was performed within 48 h of admission in AP, and all EUS findings were retrospectively analyzed.

RESULTS

Among 90 patients, 27 (30%) were diagnosed with severe AP. Multivariate analysis revealed the presence of peripancreatic fluid (OR 13.9, 95%, CI: 1.6-123.6), heterogenous (OR 7.2, 95% CI: 1.7-30.4) and hypoechoic parenchymal echogenicity (OR 10.0, 95% CI: 3.9-25.8) were significant EUS features in AP, as compared to those in the control group. Comparison between mild and severe AP showed that geographic hyperechoic area (GHA) of pancreas was a predictive factor (OR 2.9, 95% CI: 1.1-8.2, p = 0.04) for the severe form, and that AP patients with GHA had significantly longer duration of fever, abdominal pain and hospital stay than those without GHA (5.5 vs. 1 day (s), p = 0.002; 4 vs. 3 days, p = 0.023; 11 vs. 8 days, p = 0.021, respectively).

CONCLUSIONS

Typical EUS features of AP are a heterogenous hypoechoic parenchymal changes with peripancreatic fluid collection. The novel EUS variable of GHA in the early phase of AP seems to have prognostic value and could be correlated with a worse clinical outcome.

The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment

An international working group has modified the Atlanta classification for acute pancreatitis to update the terminology and provide simple functional clinical and morphologic classifications. The modifications (a) address the clinical course and severity of disease, (b) divide acute pancreatitis into interstitial edematous pancreatitis and necrotizing pancreatitis, (c) distinguish an early phase (1st week) and a late phase (after the 1st week), and (d) emphasize systemic inflammatory response syndrome and multisystem organ failure. In the 1st week, only clinical parameters are important for treatment planning. After the 1st week, morphologic criteria defined on the basis of computed tomographic findings are combined with clinical parameters to help determine care. This revised classification introduces new terminology for pancreatic fluid collections. Depending on presence or absence of necrosis, acute collections in the first 4 weeks are called acute necrotic collections or acute peripancreatic fluid collections. Once an enhancing capsule develops, persistent acute peripancreatic fluid collections are referred to as pseudocysts; and acute necrotic collections, as walled-off necroses. All can be sterile or infected. Terms such as pancreatic abscess and intrapancreatic pseudocyst have been abandoned. The goal is for radiologists, gastroenterologists, surgeons, and pathologists to use the revised classifications to standardize imaging terminology to facilitate treatment planning and enable precise comparison of results among different departments and institutions.

Cytokines and organ failure in acute pancreatitis: inflammatory response in acute pancreatitis

OBJECTIVES

We aimed at synchronously examining the early time course of 4 proinflammatory cytokines as predictive factors for development of organ failure in patients with acute pancreatitis (AP).

METHODS

Interleukin (IL) 6, IL-8, IL-18, and tumor necrosis factor α were measured on admission and at days 1, 2, and 14 in 60 patients admitted with first attack of AP. The prediction of single-organ and multiorgan failure from the cytokine profiles was evaluated by receiver operating characteristic analyses.

RESULTS

Interleukin 6 and IL-8 levels were significantly higher in patients who developed renal, respiratory, and circulatory failure, as was the case for patients with multiorgan failure. Interleukin 18 levels were significantly elevated in renal and respiratory failure only. Tumor necrosis factor α was significantly elevated in all types of organ failures, except for intestinal failure.

CONCLUSIONS

Synchronous measurements of 4 cytokines demonstrated IL-6 and IL-8 to be predictive as early surrogate markers with regard to organ failures in AP. The fact that all of the cytokines were particularly elevated in patients with organ failures calls for evaluation of agents modifying the severe inflammatory response in patients with AP.

Changes in antibiotic distribution due to pancreatitis

This work sought to define how pancreatitis affected antibiotic distribution in a perfused rat pancreas model. The distribution kinetics of four antibiotics were examined in control animals and animals with pancreatitis. Meropenem and piperacillin distributed into the extracellular space, and their distribution kinetics were unaffected by pancreatitis. In contrast, in pancreatic cells from animals with pancreatitis, ciprofloxacin showed a reduced uptake and clindamycin showed a reduced distribution.

Progress in the management of necrotizing pancreatitis

Pancreatic necrosis, a complication of severe pancreatitis, may become infected, resulting in significant morbidity and potential mortality. Infected necrosis was heretofore considered a surgical condition, and despite aggressive operative management, the mortality remained high. With a better understanding of the natural history of necrosis, established methods to diagnose infection and the increasing use of minimally invasive techniques, less aggressive therapies have been utilized with some success. The present study evaluated a step-up approach for the treatment of infected pancreatic necrosis, utilizing endoscopic and percutaneous techniques, and if ineffective, necrosectomy with a minimally invasive retroperitoneal approach. They compared this step-up approach to the standard open necrosectomy. They demonstrated that when using such an approach compared with open necrosectomy, the frequency of major complications such as organ failure, perforation, fistula or even death was significantly less than in those who received conventional open necrosectomy. Indeed, for those randomized to the step-up approach, roughly a third of the patients were successfully treated with percutaneous drainage alone. In the long-term, development of diabetes was also less frequent in those receiving less aggressive therapy. These findings, in combination with other reports, suggest that the dogma that open necrosectomy is mandatory for all patients with infected necrosis should be re-evaluated, and that less aggressive treatments as part of a multidisciplinary approach can reduce morbidity and mortality.

Practice and yield of early CT scan in acute pancreatitis: a Dutch Observational Multicenter Study

BACKGROUND

Early computed tomography (CT) (within 4 full days after symptom onset) may be performed to distinguish acute pancreatitis (AP) from other intra-abdominal conditions or to identify early pancreatic necrosis. We analyzed practice and yield of early CT in patients with an established clinical diagnosis of AP in a Dutch cohort (EARL study).

METHODS

Multicenter observational study. Etiology, disease course, CT timing, Balthazar CT score, and clinical management were evaluated.

RESULTS

First documented hospital admissions of 166 patients were analyzed. Etiology was biliary (42.8%), unknown (20.5%), alcoholic (18.1%), post-endoscopic retrograde cholangiopancreatography (11.4%), and miscellaneous (7.2%). In 89.2% (148/166), the disease course was mild. Out of 18 patients with severe AP, 11 eventually developed (peri)pancreatic necrosis. At least one CT (range 1-12) was performed in 47% (78/166) of all patients and in 62.8% (49/78) it was acquired within 4 full days after symptom onset. Practice, timing, and Balthazar CT score of early CTs were not significantly different between mild and severe AP. None of the early CTs showed necrosis and no alternative diagnoses were established. In 89.8% (44/49), clinical management was not altered after early CT. In 10.2% (5/49), prophylactic antibiotics were started, but in absence of necrosis.

CONCLUSIONS

A CT scan was frequently acquired early in the course of AP, but its yield was low and had no implications with regard to clinical management. It seems prudent that clinicians should be more restrictive in the use of early CT, in particular in mild AP, to prevent unnecessary radiation exposure and to save costs.

Characteristics and outcomes of patients undergoing debridement of pancreatic necrosis

BACKGROUND

Pancreatic necrosis is associated with high morbidity and mortality. The Atlanta Classification underwent proposed revisions in 2007 to better categorize acute pancreatitis.

METHODS

From 1999 to 2008, patients with pancreatic necrosis treated with surgical debridement were analyzed. Computed tomography (CT) images were independently reviewed to classify of pancreatic collections according to the revised Atlanta classification.

RESULTS

Seventy-three patients were categorized as infected extrapancreatic necrosis (40%), sterile extrapancreatic necrosis (29%), infected pancreatic necrosis (15%), sterile pancreatic necrosis (11%), or post-necrotic collection (5%). Mortality was 14%, and morbidity was 55%. Debridement with external drainage or open packing was associated with higher mortality than cystgastrostomy (p = 0.03). Atlanta Classification was not associated with operative procedure or mortality. Degree of chronic disease, demonstrated by albumin level, and infection were associated with longer stay (p < 0.05).

CONCLUSION

Type of necrosis by the revised Atlanta Classification was not associated with outcomes or type of operation. Debridement by cystgastrostomy was associated with lower mortality rates than external drainage or open packing. Length of stay was increased in patients with evidence of chronic disease, infection, and postoperative complications. Necrotizing pancreatitis continues to be associated with significant morbidity and mortality and should undergo aggressive treatment at tertiary care centers.

Therapeutic effect of sandostatin with salviae miltiorrhizae on experimental severe acute pancreatitis

AIM: To study therapeutic effects of sandostatin (SS) with salviae miltiorrhizae (SM) on experimental acute necrotizing pancreatitis (ANP).

METHODS: ANP models were induced by retrograde injection of 15 g/L sodium deoxycholate. Forty rats and one hundred fifty mice were randomly divided into five groups: ANP group, sham group, SS group, SM group and combination group with fifty mice and eight rats in each group respectively. Three-day mortality rate of mice was estimated. Serum amylase, NO, endotoxin, TNF-α and IL-6 24 h after the injection were measured and pancreatic histological changes were examined using light microscopy.

RESULTS: Compared with sham group, 3-d mortality rate in mice, amylase, NO, endotoxin, TNF-α and IL-6 of rats in 24 h ANP group were significantly higher (83.3% vs 0.0%, 1521.3 ± 57.9 U/dL vs 659.5 ± 58.7 U/dL, 115.2 ± 9.7 mmol/L vs 34.3 ± 2.1 mmol/L, 0.438 ± 0.137 EU/mL vs 0.029 ± 0.012 EU/mL, 191.7 ± 14.1 ng/L vs 47.5 ± 5.8 ng/L, 152.4 ± 14.7 ng/L vs 41.7 ± 5.8 ng/L, all P < 0.01), and the damage to pancreatic tissue observed by light microscopy was more severe. Compared with ANP group, the above-mentioned indexes of SM group, SS group and combination group were obviously improved (P < 0.05), especially in combination group (P < 0.05).

CONCLUSION: The therapeutic effect of sandostatin with salviae miltiorrhizae inoidesellis on ANP is superior to western medicine or traditional Chinese medicine used alone.

[Acute pancreatitis]

Acute pancreatitis is potentially fatal. It can be diagnosed based on present history, clinical appearance, and typical findings from laboratory and radiologic investigations. All patients must be admitted to hospital, as the disease course cannot be predicted at initial presentation. Increasing severity demands increasingly individualized therapy. The most important interventions are fast fluid resuscitation and analgesic therapy with opioids. Therapeutic agents specific to pancreatitis have failed to show any advantages so far. The roles of antibiotic therapy and nutritional support in the therapeutic regimen have been profoundly reassessed during recent years. Surgery and endoscopic interventions may be necessary and beneficial in carefully selected patients. In this review we summarize clinically relevant issues of acute pancreatitis.

Imaging of acute pancreatitis and its complications

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.