Mean muscle attenuation correlates with severe acute pancreatitis unlike visceral adipose tissue and subcutaneous adipose tissue

Beyond body mass index: exploring the role of visceral adipose tissue in intensive care unit outcomes

Obesity is a worldwide health crisis and poses significant challenges in critical care. Many studies suggest an 'obesity paradox', in which obesity, defined by body mass index (BMI), is associated with better outcomes. However, the inability of BMI to discriminate between fat and muscle or between visceral adipose tissue and subcutaneous adipose tissue, limits its prediction of metabolic ill health. We suggest that the 'obesity paradox' may be more reflective of the limitations of BMI than the protective effect of obesity. We explore the biological processes leading to visceral fat accumulation, and the evidence linking it to outcomes in critical illness. In the 'spillover' hypothesis of adipose tissue expansion, caloric excess and impaired expansion of storage capacity in the subcutaneous adipose tissue lead to accumulation of visceral adipose tissue. This is associated with a chronic inflammatory state, which is integral to the link between visceral adiposity, type 2 diabetes mellitus, and ischaemic heart disease. We review the current evidence on visceral adiposity and critical illness outcomes. In COVID-19, increased visceral adipose tissue, irrespective of BMI, is associated with more severe disease. This is mirrored in acute pancreatitis, suggesting visceral adiposity is linked to poorer outcomes in some hyperinflammatory conditions. We suggest that visceral adiposity's chronic inflammatory state may potentiate acute inflammation in conditions such as COVID-19 and acute pancreatitis. Further work is required to investigate other critical illnesses, especially sepsis and acute respiratory distress syndrome, in which current evidence is scarce. This may give further insights into pathophysiology and inform tailored treatment and nutrition strategies based on body fat distribution.

Myosteatosis predicts the prognosis of patients with ST-elevation myocardial infarction who undergo emergency percutaneous coronary intervention

Objective

To investigate the value of myosteatosis in predicting the prognosis of patients with ST-elevation myocardial infarction (STEMI).

Methods

This retrospective study involved 324 patients with STEMI who had undergone emergency percutaneous coronary intervention (PCI) at our institution between 2017 and 2020. Myosteatosis was assessed using mean muscle attenuation (MMA). Cox proportional hazards models were utilized to identify prognostic determinants required for the construction of a nomogram. The discriminatory performance of the nomogram was assessed via calibration curve analysis.

Results

Among the 324 patients, 35 patients (10.8%) died during the follow-up period. A lower MMA was observed in patients who died after discharge. In the multivariate analysis, MMA was identified as an independent prognostic factor. The optimal cutoff MMA value for the prediction of all-cause mortality was 32.5 Hu. The patients were classified into high (≥32.5, n=208) and low (<32.5, n=116) MMA groups. Compared with patients in the high-MMA group, patients in the low-MMA group had shorter overall survival (OS). Finally, nomograms for OS that integrate the MMA and other clinical parameters were constructed. The calibration analysis revealed that the nomograms accurately predicted the 1-, 3- and 5-year OS rates of patients.

Conclusions

Myosteatosis was associated with poorer survival outcomes in STEMI patients who underwent emergency PCI. A novel risk model comminating myosteatosis with other common clinical indicators can accurately predict the prognosis of STEMI patients.

Measurement of adipose body composition using an artificial intelligence-based CT Protocol and its association with severe acute pancreatitis in hospitalized patients

BACKGROUND/OBJECTIVES

The clinical utility of body composition in predicting the severity of acute pancreatitis (AP) remains unclear. We aimed to measure body composition using artificial intelligence (AI) to predict severe AP in hospitalized patients.

METHODS

We performed a retrospective study of patients hospitalized with AP at three tertiary care centers in 2018. Patients with computer tomography (CT) imaging of the abdomen at admission were included. A fully automated and validated abdominal segmentation algorithm was used for body composition analysis. The primary outcome was severe AP, defined as having persistent single- or multi-organ failure as per the revised Atlanta classification.

RESULTS

352 patients were included. Severe AP occurred in 35 patients (9.9%). In multivariable analysis, adjusting for male sex and first episode of AP, intermuscular adipose tissue (IMAT) was associated with severe AP, OR = 1.06 per 5 cm2, p = 0.0207. Subcutaneous adipose tissue (SAT) area approached significance, OR = 1.05, p = 0.17. Neither visceral adipose tissue (VAT) nor skeletal muscle (SM) was associated with severe AP. In obese patients, a higher SM was associated with severe AP in unadjusted analysis (86.7 vs 75.1 and 70.3 cm2 in moderate and mild, respectively p = 0.009).

CONCLUSION

In this multi-site retrospective study using AI to measure body composition, we found elevated IMAT to be associated with severe AP. Although SAT was non-significant for severe AP, it approached statistical significance. Neither VAT nor SM were significant. Further research in larger prospective studies may be beneficial.

Impact of Hepatic Steatosis, Psoas Muscle Mass, and Density on Outcomes in Patients with Moderately Severe and Severe Acute Pancreatitis: A Serial Computed Tomography-Based Retrospective Study

Background and Objective There is limited literature on the association of fatty liver and muscle mass with outcomes of acute pancreatitis (AP) in Indian patients. We aim to investigate the impact of these parameters on clinical outcomes in AP patients based on serial computed tomography (CT) scans.

Materials and Methods Consecutive patients of AP who had a baseline CT scan within 2 weeks of pain onset and a follow-up CT scan within 2 months of initial CT scan were included. Fatty liver, spleen to liver attenuation difference (AD), psoas muscle area (PMA), and psoas muscle attenuation (PMAt) were assessed on baseline and follow-up portal venous CT scans. Their association with the length of hospitalization, intensive care unit (ICU) admission, length of ICU stay, surgery, and mortality were assessed using univariate and multivariate analysis.

Results One hundred and ninety-eight patients (143 [72.2%] males, mean age 37.9 [ ± 12.4] years) were included. The mean interval between the two CT scans was 30 days (± 13.5 days). Twenty-four (12.1%) patients had fatty liver at baseline CT and 58 (29.3%) patients had fatty liver on follow-up CT (p < 0.001). The mean AD at the baseline scan was –10.2 (± 12.3) Hounsfield units (HU) and on follow up was –18.8 (± 21.7) HU (p < 0.001). PMA in baseline CT was 13.9 (± 5.5) mm2 and on follow-up was 11.2 (± 4.6) mm2 (p < 0.001). PMAt on baseline CT was 49.2 (± 8.2) HU and on follow-up was 47.1 (± 12.1) HU (p < 0.001). In multivariate analysis, the PMA and PMAt were significantly associated with the clinical outcomes. There was no association of fatty liver with clinical outcomes. The parameter with the highest area under the curve for predicting clinical outcomes was PMAt at follow-up CT.

Conclusion Psoas muscle-based assessment is associated with clinical outcomes in patients with AP.

Clinical and imaging predictors for the development of diabetes mellitus following a single episode of acute pancreatitis in youth

BACKGROUND

Acute pancreatitis (AP) increases the risk of diabetes mellitus (DM). Our aim was to identify clinical, laboratory and imaging predictors of preDM/DM in youth post index AP.

METHODS

This was a prospective cohort study of patients ≤21 years-old with an index admission for AP and follow up at 3 and/or 12 months. Clinical laboratory values, imaging findings, admission course, and plasma chemokine and cytokine measures collected at index admission were tested for association with preDM/DM development. A multivariable regression model was used to predict preDM/DM.

RESULTS

Among 187 enrolled participants, 137 (73 %) and 144 (77 %) underwent DM screening at 3 and 12 months respectively, and 137 (73 %) had imaging available. PreDM/DM occurred in 22/137 (16 %; preDM n = 21, DM n = 1) at 3 months and 23/144 (16 %; preDM n = 18, DM n = 5) participants at 12 months. Univariate associations with preDM/DM at 12 months included: severe AP (SAP) (52 % preDM/DM vs. 17 % no DM; p = 0.0008), median [IQR] IL-6 (910 pg/ml [618-3438] vs. 196 pg/ml [71-480], p < 0.05) and CRP (4.16 mg/L [1.67-10.7] vs. 1.55 mg/L [0.4-3.68], p = 0.1) at time of AP attack. The optimal multivariable model to predict preDM/DM included with clinical variables was severe acute pancreatitis (SAP), c reactive protein (CRP), interleukin-6 (IL-6), and age [AUC = 0.80; (0.70, 0.88)]. Including imaging markers, the ideal model included SAP, CRP, IL-6, subcutaneous fat area, age and presence of autoimmune disease with an AUC [0.82 (0.71, 0.90)].

CONCLUSIONS

Development of preDM/DM following an index AP episode can be predicted by baseline AP severity, baseline CRP, IL-6 levels, and subcutaneous fat area.

Visceral adipose tissue area predicts major adverse kidney events in patients with acute necrotizing pancreatitis

BACKGROUND

Given the previously reported harmful effects of abdominal fat burden on kidney function, we aim to investigate the relationship between major adverse kidney events within 30 days (MAKE30) and abdominal obesity in acute necrotizing pancreatitis (ANP) patients and explore the underlying risk factors.

METHODS

A retrospective cohort study of all patients admitted within 72 h after the first episode of ANP to a tertiary center between June 2015 and June 2019 was conducted. Automatic image analysis software was used to calculate the area of subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT) and skeletal muscle from computed tomography scans at the umbilical level. The potential risk factors of MAKE30 were analyzed by logistic regression.

RESULTS

A total of 208 eligible ANP patients were enrolled, with an incidence of 23% for MAKE30. VAT area was more closely associated with the development of MAKE30, with an area under the ROC curve of 0.69 (cutoff value 200 cm2, 63.8% sensitivity and 66.7% specificity). Multivariate logistic regression analysis demonstrated that VAT area [OR 1.01 (1.01-1.02); p < 0.001] was an independent risk factor in predicting MAKE30. Patients with a VAT area > 200 cm2 had more requirements of renal replacement therapy (32% vs. 12%, P < 0.001), and a significantly higher incidence of other poor clinical outcomes (all p < 0.05).

CONCLUSION

Early assessment of the VAT area may help identify ANP patients at high risk of MAKE30, suggesting that it could be a potential indicator for adverse kidney events.

Beyond Traditional Body Composition Metrics: Load-Capacity Indices Emerge as Predictors of Cardiometabolic Outcomes-A Systematic Review and Meta-Analysis

The adaptive and independent interrelationships between different body composition components have been identified as crucial determinants of disease risk. On the basis of this concept, the load-capacity model of body composition, which utilizes measurements obtained through nonanthropometric techniques such as dual-energy X-ray absorptiometry, was proposed. This model is typically operationalized as the ratio of metabolic load (adipose mass) to metabolic capacity (lean mass). In recent years, a series of load-capacity indices (LCIs) have been utilized to identify abnormal body composition phenotypes such as sarcopenic obesity (SO) and to predict the risk of metabolic, cardiovascular, and cognitive disorders. In this review, we comprehensively review the characteristics of different LCIs used in previous studies, with a specific focus on their applications, especially in identifying SO and predicting cardiometabolic outcomes. A systematic literature search was performed using PubMed, MEDLINE, PsycINFO, Embase, and the Cochrane Library. Two meta-analyses were conducted to 1) estimate the overall prevalence of SO mapped by LCIs, and 2) assess the association of LCIs with cardiometabolic outcomes. A total of 48 studies (all observational) were included, comprising 22 different LCIs. Ten studies were included in the meta-analysis of SO prevalence, yielding a pooled prevalence of 14.5% [95% confidence interval (CI): 9.4%, 21.6%]. Seventeen studies were included in the meta-analysis of the association between LCIs and adverse cardiometabolic outcomes, which showed a significant association between higher LCI values and increased risk (odds ratio = 2.22; 95% CI: 1.81, 2.72) of cardiometabolic diseases (e.g. diabetes and metabolic syndrome). These findings suggest that the load-capacity model of body composition could be particularly useful in the identification of SO cases and prediction of cardiometabolic risk. Future longitudinal studies are needed to validate the association of LCIs with chronic cardiometabolic and neurodegenerative diseases. This systematic review and meta-analysis has been registered with PROSPERO (CRD42024457750).

Role and mechanism of myonectin in severe acute pancreatitis: a crosstalk between skeletal muscle and pancreas

BACKGROUND

Severe acute pancreatitis (SAP) is characterized by high mortality rates and various complications, including skeletal muscle atrophy, which significantly exacerbates its outcomes. Despite its clinical relevance, the mechanistic understanding of the relationship between skeletal muscle and the pancreas in SAP remains limited. Our study aimed to elucidate this "organ crosstalk" and its potential implications.

METHODS

We established an SAP mouse model through pancreatic duct ligation (PDL) and evaluated pancreatic necrosis, skeletal muscle atrophy, and myonectin expression levels. Recombinant myonectin protein was administered in vivo and in vitro to assess its effects on acinar cell necrosis. Mechanistic insights were gained through RNA-seq data analysis and experimental validation. Serum samples from AP patients and healthy controls were collected to investigate the correlation between serum myonectin levels and disease severity.

RESULTS

The mouse model exhibited severe pancreatic necrosis, skeletal muscle atrophy, and elevated myonectin levels, with myonectin administration exacerbating model severity. We identified iron accumulation-induced ferroptosis as a key pathway contributing to myonectin-mediated acinar cell necrosis. A total of 22 healthy controls and 52 patients with varying degrees of AP were included in the serum samples and clinical data (36.5% females, age 49.79 ± 16.53). Analysis of serum samples revealed significantly higher myonectin levels in AP patients, correlating with disease severity (R = 0.28, P = 0.041).

CONCLUSIONS

Our findings underscore the significant role of myonectin in SAP progression and its potential as a prognostic marker for disease severity in AP patients. This study contributes to a deeper understanding of the pathophysiology of SAP and highlights potential therapeutic targets for intervention.

Visceral adipose tissue predicts severity and prognosis of acute pancreatitis in obese patients

Acute pancreatitis is a common systemic inflammatory disease, manifested by a spectrum of severity, ranging from mild in the majority of patients to severe acute pancreatitis. Patients with severe acute pancreatitis suffer from severe local and systemic complications and organ failure, leading to a poor prognosis. The early recognition of the severe condition is important to improve prognosis. Obesity has risen in tandem with an increase in the severity of acute pancreatitis in recent years. Studies have revealed that adipose tissue, particularly visceral adipose tissue is associated with the prognosis of acute pancreatitis. This review discussed the role of visceral adipose tissue in obese patients with acute pancreatitis and explored the possible mechanism involved.

Sarcopenia and Sarcopenic Obesity on Body Composition Analysis is a Significant Predictor of Mortality in Severe Acute Pancreatitis: A Longitudinal Observational Study

BACKGROUND

The prevalence and impact of sarcopenia and sarcopenic obesity noted on body composition analysis in severe acute pancreatitis (SAP) is unknown. This study investigates the prevalence of sarcopenia at different timepoints and its effect on post-pancreatitis complications and mortality.

METHODS

A prospective database of SAP admissions with organ failure at a single institution from 2015 to 2019 were analysed. Sarcopenia was determined by IMAGE J software on CT. Database was further queried for post-pancreatitis complications and mortality.

RESULTS

141 patients with a median age of 59 (range 18-88) and M:F ratio 1.52:1 of were analysed. Sarcopenia was present in 111/141 (79%) patients at admission, 78/79 (99%) at 3 months and 26/36 (72%) at 12 months. 67/111 patients with sarcopenia on admission had sarcopenic obesity. The mortality at 30 days, 3 months and 12 months was 16/141 (11%), 30/141 (21%) and 42/141 (30%) respectively. Mortality was significantly higher in sarcopenic patients at admission (35.14%) compared to the non-sarcopenic group (10%), P = 0.008). Mortality in the sarcopenic obesity group was significantly higher (45%) compared to the sarcopenic non-obese group (20%), P = 0.009) at admission. Multivariate logistic regression identified sarcopenic obesity (OR: 2.880), age (OR: 1.048) and number of organ failures (OR: 3.225) as significant predictors of mortality.

CONCLUSIONS

Sarcopenia and Sarcopenic obesity are highly prevalent in SAP patients on admission and during follow up. Furthermore, sarcopenic obesity was shown to be a significant predictor of mortality at admission, suggesting that body composition analysis could be a potential predictive marker of mortality in SAP patients.

Relationship of computed tomography quantified visceral adiposity with the severity and complications of acute pancreatitis: a systematic review

Whilst obesity and visceral adipose tissue (VAT) have been reported to be associated with an increased risk of severe AP, the established predictive scoring systems have not yet encompassed the impact of obesity or visceral adiposity. In the acute setting, computed tomography (CT) is often performed to assess AP severity and associated complications. With the added benefit of quantifying body fat distribution, it can be opportunistically used to quantify visceral adiposity and assess its relationship with the course of AP. This systematic review identified fifteen studies evaluating the relationship between visceral adiposity measured on CT and the severity of presentations of acute pancreatitis from January 2000 to November 2022. The primary outcome was to assess the relationship between CT quantified VAT and AP severity. The secondary outcomes were to assess the impact of VAT on patients developing local and systemic complications associated with AP. Whilst ten studies showed there was a significant correlation between an increased VAT and AP severity, five studies found otherwise. The majority of current literature demonstrate a positive correlation between increased VAT and AP severity. CT quantification VAT is a promising prognostic indicator with the potential to guide initial management, prompt more aggressive treatment measures or earlier re-evaluation and to aid disease prognostication in patients with acute pancreatitis.

Effectiveness of neuromuscular electrical stimulation in severe acute pancreatitis complicated patients with acute respiratory distress syndrome: study protocol for a randomized controlled trial

BACKGROUND

Severe acute pancreatitis complicated by acute respiratory distress is a common cause of intensive care unit (ICU) admission. These patients are at risk of a decline in physical activity due to bed rest. Neuromuscular electrical stimulation (NMES) has been recommended for ICU patients to strengthen muscles, but its effects on muscle atrophy, respiratory function, multiple organ dysfunction, and functional status of these patients remain to be proven.

METHODS

Patients (n = 80) will be prospectively randomized into an NMES group and a control group. The NMES group will receive NMES for 1 h per day for 7 days, and both the control and NMES groups will receive usual care. The efficacy will be assessed by an experienced physiotherapist and sonographer who will be blinded to the patient's group assignment. Muscle power assessment (MRC scale), lower extremity circumference, grip strength, activities of daily living (Barthel index), and Marshall scores will be measured at baseline and posttreatment. The functions of the diaphragm assessments will be measured daily. Barthel index measurements will be followed up in the 1st month, 3rd month, and 6th month after discharge.

DISCUSSION

The trial will explore the effectiveness of NMES in functional status and diaphragm function in patients with SAP complicated with ARDS. The results of this trial will provide strong evidence of the efficacy of NMES in treating SAP patients with ARDS.

TRIAL REGISTRATION

This trial has been registered at the Chinese Clinical Trial Registry, and the registry name is "Effectiveness of neuromuscular electrical stimulation in severe acute pancreatitis complicated patients with acute respiratory distress syndrome: study protocol for a randomized controlled trial," URL: https://www.chictr.org.cn , numbered ChiCTR2300068995. Date of Registration: 2023-03-03.

Impact of sarcopenic obesity on predicting the severity of acute pancreatitis

BACKGROUND AND AIMS

This work aimed to evaluate the impact of sarcopenia and sarcopenic obesity on the occurrence of severe pancreatitis and to study the performance of anthropometric indices to predict severe forms.

METHODS

We conducted a single-center retrospective study at Caen University Hospital between 2014 and 2017. Sarcopenia was assessed by measuring the psoas area on an abdominal scan. The psoas area /body mass index ratio reflected sarcopenic obesity. By normalizing the value to the body surface, we obtained an index called sarcopancreatic index, avoiding sex differences in measurements.

RESULTS

Among 467 included patients, 65 (13.9%) developed severe pancreatitis. The sarcopancreatic index was independently associated with the occurrence of severe pancreatitis (1.455 95% CI [1.028-2.061]; p = 0.035), as was the Visual Analog Scale, creatinine or albumin. The complication rate was not different depending on sarcopancreatic index value. Based on variables independently associated with the occurrence of severe pancreatitis, we constructed a score called Sarcopenia Severity Index. This score presented an area under the receiver operating characteristics curve of 0.84, comparable to the Ranson score (0.87) and superior to body mass index or the sarcopancreatic index to predict a severe form of acute pancreatitis.

CONCLUSIONS

Sarcopenic obesity seems to be associated with severe acute pancreatitis.

The Visceral-to-subcutaneous Adipose Tissue Area Ratio Is Associated with Retreatment in Chronic Pancreatitis Patients with Pancreatolithiasis after Extracorporeal Shock Wave Lithotripsy

Objective Extracorporeal shock wave lithotripsy (ESWL) has been used to treat pancreatolithiasis in patients with chronic pancreatitis (CP), but the high recurrence rate remains challenging. We therefore evaluated the association between body composition parameters and the prediction of retreatment after ESWL. Methods This study retrospectively evaluated 42 patients with CP who had been treated with ESWL between 2008 and 2019 in a single center. Body composition parameters were measured on pretreatment computed tomography images. Patients who underwent repeat ESWL were classified as the retreatment group. Results There were 13 (31.0%) and 29 (69.0%) patients in the retreatment and non-retreatment groups, respectively. The visceral-to-subcutaneous adipose tissue area ratio (VSR) of the retreatment group was significantly lower than that of the non-retreatment group (p=0.016). When divided by the median VSR, 10 of the 20 patients with a VSR of <0.85 underwent retreatment, whereas 3 of the 22 patients with a VSR of ≥0.85 underwent retreatment (p=0.019). According to a multivariate analysis, the VSR (p=0.010) and age (p=0.037) were independent factors associated with retreatment after ESWL. Conclusion This study showed that the VSR can predict the retreatment of patients with CP after ESWL.

The modified computed tomography severity index combined with low skeletal muscle mass can better predict the severity of hypertriglyceridemia-induced pancreatitis

BACKGROUND

Body composition parameters are associated with hypertriglyceridemia-induced pancreatitis (HTGP). This study investigated the association between the quantity of muscle assessed using computed tomography (CT) and the severity of HTGP.

METHODS

The modified CT severity index (MCTSI) was calculated from admission examination data. Patients' characteristics and body composition parameters were collected. Univariate and multivariate logistic regression analyses were also performed. The receiver operating characteristic curves and corresponding area under the curves (AUC) were calculated to test the efficiency of the model. A nomogram was then constructed.

RESULTS

Of the 175 included patients, 138 were male, of which 85 had moderately severe to severe HTGP. Patients with low skeletal muscle mass (LSMM) and high MCTSI were significantly more likely to have moderately severe to severe HTGP. Patients with LSMM had lower body mass index, lower HDL-C level, higher amylase level, prevalence of surgery, shorter umbilical waist circumference, and longer length of hospital stay. Univariate and multivariate logistic regression analyses confirmed that female sex, lipase, total cholesterol, LSMM-MCTSI (P = .004, odds ratio = 23.105), and albumin were risk factors. The TOTAL model that combined LSMM-MCTSI and clinical risk parameters performed best (AUCs = 0.875), followed by other models (LSMM-MCTSI: AUCs = 0.762, MCTSI: AUCs = 0.728). The Delong test revealed significant difference. Finally, a nomogram was developed to predict the severity of HTGP.

CONCLUSION

The performance of MCTSI in predicting severity can be improved by considering LSMM, which is a promising strategy for the treatment of HTGP.

Predicting Severity of Acute Pancreatitis

Acute pancreatitis has a diverse etiology and natural history, and some patients have severe complications with a high risk of mortality. The prediction of the severity of acute pancreatitis should be achieved by a careful ongoing clinical assessment coupled with the use of a multiple-factor scoring system and imaging studies. Over the past 40 years, various scoring systems have been suggested to predict the severity of acute pancreatitis. However, there is no definite and ideal scoring system with a high sensitivity and specificity. The interest in new biological markers and predictive models for identifying severe acute pancreatitis testifies to the continued clinical importance of early severity prediction. Although contrast-enhanced computed tomography (CT) is considered the gold standard for diagnosing pancreatic necrosis, early scanning for the prediction of severity is limited because the full extent of pancreatic necrosis may not develop within the first 48 h of presentation. This article provides an overview of the available scoring systems and biochemical markers for predicting severe acute pancreatitis, with a focus on their characteristics and limitations.

Impact of myopenia and myosteatosis in patients undergoing abdominal surgery for chronic pancreatitis

BACKGROUND

Surgery for chronic pancreatitis is associated with major morbidity and mortality. The aim of this study is to examine the role of preoperative muscle volume and quality on postoperative outcomes in patients with chronic pancreatitis.

METHODS

All patients who underwent abdominal surgery for chronic pancreatitis between 2011 and 2018 were identified from an institutional surgical database. Patient demographics, clinical indices, and perioperative computed tomography scans were collected. Myopenia and myosteatosis were measured at the L3 vertebral level. Regression analysis was used to identify risk factors for major complications (Clavien-Dindo ≥3a) and length of stay.

RESULTS

Seventy-five patients were identified. Toxic-metabolic or obstructive causes were the main underlying etiologies. Thirty patients were myopenic (40%), and 36 patients were myosteatotic (48%). Sixteen patients (21%) had a major complication. Median length of stay was 10 days. Both myopenia and myosteatosis were associated with major complications (hazard ratio = 7.85, 95% confidence interval: 1.91-32.29, P = .004 and hazard ratio = 4.351, 95% confidence interval: 1.22-15.52, P = .023). Myosteatosis was associated with increased length of stay (parameter estimate = 0.297, 95% confidence interval: 0.012-0.583, P = .041).

CONCLUSION

Myopenia and myosteatosis were common and significant risk factors for adverse postoperative events. Preoperative muscle assessment may help in the risk stratification of surgical patients and identify patients that require preoperative nutritional and physical optimization.

Pleuropulmonary pathologies in the early phase of acute pancreatitis correlate with disease severity

Background

Respiratory failure worsens the outcome of acute pancreatitis (AP) and underlying factors might be early detectable.

Aims

To evaluate the prevalence and prognostic relevance of early pleuropulmonary pathologies and pre-existing chronic lung diseases (CLD) in AP patients.

Methods

Multicentre retrospective cohort study. Caudal sections of the thorax derived from abdominal contrast enhanced computed tomography (CECT) performed in the early phase of AP were assessed. Independent predictors of severe AP were identified by binary logistic regression analysis. A one-year survival analysis using Kaplan-Meier curves and log rank test was performed.

Results

358 patients were analysed, finding pleuropulmonary pathologies in 81%. CECTs were performed with a median of 2 days (IQR 1–3) after admission. Multivariable analysis identified moderate to severe or bilateral pleural effusions (PEs) (OR = 4.16, 95%CI 2.05–8.45, p<0.001) and pre-existing CLD (OR = 2.93, 95%CI 1.17–7.32, p = 0.022) as independent predictors of severe AP. Log rank test showed a significantly worse one-year survival in patients with bilateral compared to unilateral PEs in a subgroup.

Conclusions

Increasing awareness of the prognostic impact of large and bilateral PEs and pre-existing CLD could facilitate the identification of patients at high risk for severe AP in the early phase and thus improve their prognosis.

Impacts of body composition parameters and liver cirrhosis on the severity of alcoholic acute pancreatitis

AIM

Liver cirrhosis and features of muscle or adipose tissues may affect the severity of acute pancreatitis (AP). We aimed to evaluate the impact of body composition parameters and liver cirrhosis on the severity of AP in patients with alcohol-induced AP (AAP).

METHODS

Patients with presumed AAP who underwent CT within one week after admission were retrospectively enrolled. L3 sectional areas of abdominal fat and muscle, and mean muscle attenuations (MMAs) were quantified. The presence of liver cirrhosis was determined using clinical and CT findings. Factors potentially associated with moderately severe or severe AP were included in the multivariable logistic regression analysis.

RESULTS

A total of 242 patients (47.0 ± 12.6 years, 215 males) with presumed AAP were included. The mild and moderately severe/severe (MSS) groups included 137 (56.6%) and 105 patients (43.4%), respectively. Patients in the MSS group had higher rates of liver cirrhosis, organ failure, and local complications. Among body composition parameters, mean MMA (33.4 vs 36.8 HU, P<0.0001) and abdominal muscle mass (126.5 vs 135.1 cm2, P = 0.029) were significantly lower in the MSS group. The presence of liver cirrhosis (OR, 4.192; 95% CI, 1.620-10.848) was found to be a significant risk factor for moderately severe or severe AP by multivariable analysis.

CONCLUSION

The results of this study suggest that liver cirrhosis has a significant impact on the severity of AAP. Of the body composition parameters examined, MMA and abdominal muscle mass showed potential as promising predictors.

Mechanisms of Post-Pancreatitis Diabetes Mellitus and Cystic Fibrosis-Related Diabetes: A Review of Preclinical Studies

Anatomical proximity and functional correlations between the exocrine and endocrine pancreas warrant reciprocal effects between the two parts. Inflammatory diseases of the exocrine pancreas, such as acute or chronic pancreatitis, or the presence of cystic fibrosis disrupt endocrine function, resulting in diabetes of the exocrine pancreas. Although novel mechanisms are being increasingly identified, the intra- and intercellular pathways regulating exocrine-endocrine interactions are still not fully understood, making the development of new and more effective therapies difficult. Therefore, this review sought to accumulate current knowledge regarding the pathogenesis of diabetes in acute and chronic pancreatitis, as well as cystic fibrosis.

Assessment of Acute Pancreatitis Severity and Prognosis with CT-Measured Body Composition

Objective

The aim of this study was to investigate the possible association of muscle and adipose parameters with the severity and prognosis of patients hospitalized with acute pancreatitis (AP).

Methods

A total of 392 hospitalized patients and 309 controls were enrolled in the study analysis from April 1, 2016, to February 1, 2021. The computed tomography scans of each population were evaluated for muscle and adipose parameters. The effects of parameters on developing moderately severe acute pancreatitis (MSAP) or severe acute pancreatitis (SAP) were evaluated using univariate and multivariate logistic regression analyses. Associations with disease recurrence and death were analyzed through Cox regression analysis.

Results

The AP patients had higher levels of visceral adipose tissue (144.25 vs 97.81 cm², p < 0.001) and subcutaneous adipose tissue (135 vs 120 cm², p < 0.001) but lower levels of adipose tissue attenuation (visceral and subcutaneous) and skeletal muscle attenuation (SMA) than the controls (p < 0.05, respectively). Visceral adipose tissue (VAT) and SMA differed significantly with p-values of 0.014 and 0.003 in the different severity groups of AP. In multivariate analysis, VAT and SMA were associated with MSAP or SAP, with odds ratios of 1.003 and 0.973, respectively (95% CI 1.000-1.006, p = 0.041; 95% CI 0.953-0.993, p = 0.010). Cox regression analysis showed that low SMA was strongly associated with an increased mortality in MSAP and SAP patients (HR 10.500, 95% CI 1.344-82.025, p = 0.025). Regression analysis also showed an association of VAT loss of more than 17% with reduced 1-year recurrence of acute pancreatitis (HR 0.427, 95% CI 0.189-0.967, p = 0.041).

Conclusion

VAT and SMA were influential factors for the severity and prognosis of patients with AP. Patients should proper diet and exercise after discharge to reduce VAT and strengthen muscle function to improve prognosis.

The Effects of the Fat Distribution of Body, Skeletal Muscle Mass and Muscle Quality on Acute Pancreatitis Severity: A Retrospective Cross-Sectional Study

OBJECTIVE

We aim to investigate a possible relationship between acute pancreatitis (AP) and body fat and muscle parameters in computed tomography (CT).

METHODS

Computed tomography images of 107 patients with AP were scored in terms of AP severity using the modified CT severity index. Muscle mass, muscle mass index, visceral and subcutaneous adipose tissue area, multifidus muscle/fat attenuation ratio, total psoas index (TPI) and Hounsfield units average calculation (HUAC) values were performed.

RESULTS

Total psoas index and HUAC of mild AP cases were significantly higher than those with moderate and severe AP. The TPI of patients with severe pancreatic necrosis were found to be significantly lower than those without necrosis. Hounsfield units average calculation of cases without necrosis were significantly higher than those with severe necrosis in the pancreas.

CONCLUSIONS

Our study indicated that lower volume and density of psoas muscle associated with worse CT severity score and larger pancreatic necrosis in patients with AP.

Decreased skeletal muscle density is an independent predictor of mortality in necrotizing pancreatitis- A single tertiary center experience in 507 patients

BACKGROUND AND AIMS

Necrotizing pancreatitis has a variable clinical course and it is essential to identify determinants associated with high risk of mortality and poor clinical outcomes. The aim of this study is to evaluate the association between CT-assessed body composition parameters such as visceral fat area (VFA), skeletal muscle index (SMI) and skeletal muscle density (SMD) and inpatient mortality in NP patients. Secondary outcomes include organ failure on admission, persistent organ failure, length of stay (LOS), need for ICU admission, need for endoscopic, percutaneous or surgical interventions for NP and 30-day unplanned readmission.

METHODS

All NP patients managed at a single center between 2009 and 2019 with a CT scan within a week of admission were included. SMI, SMD and VFA was calculated from CT imaging at the third lumbar vertebra and multivariable analysis was performed after correcting for age, sex, BMI, ASA classification, multi- organ failure on admission to determine independent association with inpatient mortality and secondary outcomes.

RESULTS

507 NP patients [males = 349 (68.8%), median age 53 (IQR 37-65) years were included in this study. The lowest tertile SMD was independently associated with inpatient mortality on multivariable analysis: adjusted OR 3.36 (1.57-7.2), P = 0.002. The lowest SMI tertile and highest VFA tertile were not independently associated with mortality. Lowest tertile SMD was significantly associated with persistent organ failure (OR 2.01, 95% CI 1.34-3.01, p = 0.001), need for percutaneous drainage (OR 1.84, 95% CI 1.21-2.8, p = 0.004), need for ICU admission (OR 2.32, 95% CI 1.59-3.38, p < 0.0001) and LOS.

CONCLUSION

Low SMD was independently associated with in-hospital mortality in NP patients and can be usefully incorporated in CT based predictive scoring models as a prognostic marker.

Assessment of Computed Tomography-Defined Muscle and Adipose Tissue Features in Relation to Length of Hospital Stay and Recurrence of Hypertriglyceridemic Pancreatitis

Background

Analytic morphometric assessment has recently been proposed to be applied to the study of acute pancreatitis (AP). However, the relationship between body composition and the outcomes of hypertriglyceridemic pancreatitis (HTGP) is still unclear. The aim of this study was to evaluate body composition in relation to the length of hospital stay (LOS) and recurrence of HTGP.

Methods

Patient characteristics, admission examination data, body composition parameters, LOS, and recurrence within 1 year were collected from the institutional pancreatitis database and follow-up records. Logistic regression analysis was used to identify risk factors for LOS and recurrence of HTGP.

Results

Of the 196 included patients, 158 (80.6%) were men and 53 (27.0%) were sarcopenic. The average LOS was 15.83±10.02 days. The recurrence rate of HTGP was 36.7%. Multivariate analysis with multiple linear regression suggested that subcutaneous adipose tissue (SAT) area (p=0.019) and high-density lipoprotein-cholesterol (HDL-C) (p=0.001) were independently associated with the LOS for HTGP after adjusting for age and sex. The multivariate adjusted hazard ratios for SAT area and HDL-C, with respect to the relationship between body parameters and LOS, were 1.008 (95% confidence interval [CI], 1.001–1.015) and 0.090 (95% CI, 0.022–0.361), respectively. No significant differences were observed between the AP and recurrent AP (RAP) groups in terms of characteristics, admission examination data, and body composition parameters.

Conclusion

SAT area and HDL-C are associated with LOS in patients with HTGP. The body composition of patients at the first symptom onset of HTGP cannot predict recurrence.

The association of parameters of body composition and laboratory markers with the severity of hypertriglyceridemia-induced pancreatitis

BACKGROUND

Hypertriglyceridemia has arisen as the third leading cause of acute pancreatitis. This study aimed at exploring the association between the severity of hypertriglyceridemia-induced pancreatitis (HTGP) and computed tomography (CT)-based body composition parameters and laboratory markers.

METHODS

Laboratory and clinical parameters were collected from 242 patients with HTGP between 2017 and 2020. Severity of HTGP was evaluated by original or modified CT severity index. Body composition parameters such as area and radiodensity of muscle, subcutaneous adipose tissue and visceral adipose tissue were calculated by CT at the level of third lumbar vertebra. Parameters were compared between mild and moderately severe to severe HTGP. Uni-variate and multi-variate Logistic regression analyses were employed to assess the risk factors of the severity of HTGP.

RESULTS

Seventy patients (28.9%) presented with mild HTGP. Body mass index, waist circumference and all CT-based body composition parameters differed between male and female patients. None was associated with the severity of HTGP, neither in males nor in females. Receiver operating characteristic curves showed that areas under the curves of apolipoprotein A-I and albumin to predict the severity of HTGP were 0.786 and 0.759, respectively (all P < 0.001). Uni-variate and further multi-variate Logistic regression analysis confirmed that low serum albumin (< 35 g/L, P = 0.004, OR = 3.362, 95%CI = 1.492-8.823) and apolipoprotein A-I (< 1.1 g/L, P < 0.001, OR = 5.126, 95%CI = 2.348-11.195), as well as high C-reactive protein (> 90 mg/L, P = 0.005, OR = 3.061, 95%CI = 1.407-6.659) and lipase (P = 0.033, OR = 2.283, 95%CI = 1.070-4.873) were risk factors of moderately severe to severe HTGP. Levels of albumin, apolipoprotein A-I, C-reactive protein and lipase were also associated with the length of hospital stay (all P < 0.05). Besides, low serum albumin, low-density lipoprotein cholesterol and high radiodensity of subcutaneous adipose tissue were significant risk factors of pancreatic necrosis in patients with HTGP (all P < 0.05).

CONCLUSIONS

Low serum albumin and apolipoprotein A-I, and high C-reactive protein and lipase upon admission were associated with a more severe type of HTGP and longer hospital stay for these patients. Albumin and apolipoprotein A-I may serve as novel biomarkers for the severity of HTGP. However, none of the body composition parameters was associated with the severity of HTGP.

Assessment of the course of acute pancreatitis in the light of aetiology: a systematic review and meta-analysis

The main causes of acute pancreatitis (AP) are biliary disease, alcohol consumption, hypertriglyceridaemia (HTG) and endoscopic retrograde cholangiopancreatography (ERCP). The aim of this meta-analysis was to evaluate the effects of these aetiological factors on the severity and outcome of AP. Pubmed and Embase were searched between 01/01/2012 and 31/05/2020. Included articles involved adult alcoholic, biliary, HTG- or post-ERCP AP (PAP) patients. Primary outcome was severity, secondary outcomes were organ failures, intensive care unit admission, recurrence rate, pancreatic necrosis, mortality, length of hospital stay, pseudocyst, fluid collection and systematic inflammatory response syndrome. Data were analysed from 127 eligible studies. The risk for non-mild (moderately severe and severe) condition was the highest in HTG-induced AP (HTG-AP) followed by alcoholic AP (AAP), biliary AP (BAP) and PAP. Recurrence rate was significantly lower among BAP vs. HTG-AP or AAP patients (OR = 2.69 and 2.98, 95% CI 1.55-4.65 and 2.22-4.01, respectively). Mortality rate was significantly greater in HTG-AP vs. AAP or BAP (OR = 1.72 and 1.50, 95% CI 1.04-2.84 and 0.96-2.35, respectively), pancreatic necrosis occurred more frequently in AAP than BAP patients (OR = 1.58, 95% CI 1.08-2.30). Overall, there is a potential association between aetiology and the development and course of AP. HTG-AP is associated with the highest number of complications. Furthermore, AAP is likely to be more severe than BAP or PAP. Greater emphasis should be placed on determining aetiology on admission.

Quantitative Imaging of Body Composition

Body composition refers to the amount and distribution of lean tissue, adipose tissue, and bone in the human body. Lean tissue primarily consists of skeletal muscle; adipose tissue comprises mostly abdominal visceral adipose tissue and abdominal and nonabdominal subcutaneous adipose tissue. Hepatocellular and myocellular lipids are also fat pools with important metabolic implications. Importantly, body composition reflects generalized processes such as increased adiposity in obesity and age-related loss of muscle mass known as sarcopenia.In recent years, body composition has been extensively studied quantitatively to predict overall health. Multiple imaging methods have allowed precise estimates of tissue types and provided insights showing the relationship of body composition to varied pathologic conditions. In this review article, we discuss different imaging methods used to quantify body composition and describe important anatomical locations where target tissues can be measured.

Association of visceral adipose tissue on the incidence and severity of acute pancreatitis: A systematic review

BACKGROUND

With the rising prevalence of obesity, there is a plethora of literature discussing the relationship between obesity and acute pancreatitis (AP). Evidence has shown a possible correlation between visceral adipose tissue (VAT) and AP incidence and severity. This systematic review explores these associations.

METHODS

Eligible articles were searched and retrieved using Medline and Embase databases. Clinical studies evaluating the impact of VAT as a risk factor for AP and the association of the severity of AP and VAT were included.

RESULTS

Eleven studies, with a total of 2529 individuals were reviewed. Nine studies showed a statistically significant association between VAT and the severity of AP. Only four studies found VAT to be a risk factor for acute pancreatitis. Two studies showed VAT to be associated with an increased risk of local complications and two studies showed a correlation between VAT and mortality.

CONCLUSION

This is the first systematic review conducted to study the association between VAT and AP. The existing body of evidence demonstrates that VAT has a clinically relevant impact and is an important prognostic indicator of the severity of AP. However, it has not shown to be an independent risk factor to the risk of developing AP. The impact of VAT on the course and outcome of AP needs to be profoundly explored to confirm these findings which may fuel earlier management and better define the prognosis of patients with AP. VAT may need to be incorporated into prognostic scores of AP to improve accuracy.