Severe acute pancreatitis: eight fundamental steps revised according to the 'PANCREAS' acronym

Evidence-Based Approach to the Surgical Management of Acute Pancreatitis

Background  Acute pancreatitis is a significant challenge to health services. Remarkable progress has been made in the last decade in optimizing its management.

Methods  This review is a comprehensive assessment of 7 guidelines employed in current clinical practice with an appraisal of the underlying evidence, including 15 meta-analyses/systematic reviews, 16 randomized controlled trials, and 31 cohort studies.

Results  Key tenets of early management of acute pancreatitis include severity stratification based on the degree of organ failure and early goal-directed fluid resuscitation. Rigorous determination of etiology reduces the risk of recurrence. Early enteral nutrition and consideration of epidural analgesia have been pioneered in recent years with promising results. Indications for invasive intervention are becoming increasingly refined. The definitive indications for endoscopic retrograde cholangiopancreatography in acute pancreatitis are associated with cholangitis and common bile duct obstruction. The role of open surgical necrosectomy has diminished with the development of a minimally invasive step-up necrosectomy protocol. Increasing use of endoscopic ultrasound–guided intervention in the management of pancreatic necrosis has helped reduce pancreatic fistula rates and hospital stay.

Conclusion  The optimal approach to surgical management of complicated pancreatitis depends on patient physiology and disease anatomy, in addition to the available resources and expertise. This is best achieved with a multidisciplinary approach. This review provides a distillation of the recommendations of clinical guidelines and critical discussion of the evidence that informs them and presents an algorithmic approach to key areas of patient management.

Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes

Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the “step-up approach”. This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.

Somatostatin plus Ulinastatin in the Treatment of Severe Acute Pancreatitis and Its Effect on Serum Cytokine Levels

Objective

To investigate the effect of somatostatin combined with ulinastatin in the treatment of patients with severe acute pancreatitis and its effect on serum cytokine levels.

Methods

This study is a retrospective trial. One hundred patients with severe acute pancreatitis in our hospital between March 2020 and May 2021 were recruited and assigned into the control group (ulinastatin alone) and experimental group (somatostatin plus ulinastatin) according to different treatment methods, 50 cases each. The clinical efficacy and serum cytokine levels of the two groups were compared.

Results

Somatostatin plus ulinastatin was associated with a higher total effective rate versus ulinastatin alone (p < 0.05). After treatment, the experimental group observed significantly better interleukin-10 (IL-10), interleukin-18 (IL-18), and tumor necrosis factor-α (TNF-α) when compared with those in the control group (p < 0.05); somatostatin plus ulinastatin resulted in better serum amylase, blood calcium, blood urea nitrogen, blood sugar, and white blood cell count versus ulinastatin alone (p < 0.05).

Conclusion

Somatostatin plus ulinastatin is a viable alternative in the treatment of patients with severe acute pancreatitis, with a remarkable efficacy profile. It is worthy of clinical application.

Nutritional Support in Patients with Severe Acute Pancreatitis-Current Standards

Severe acute pancreatitis (SAP) leads to numerous inflammatory and nutritional disturbances. All SAP patients are at a high nutritional risk. It has been proven that proper nutrition significantly reduces mortality rate and the incidence of the infectious complications in SAP patients. According to the literature, early (started within 24–48 h) enteral nutrition (EN) is optimal in most patients. EN protects gut barrier function because it decreases gastrointestinal dysmotility secondary to pancreatic inflammation. Currently, the role of parenteral nutrition (PN) in SAP patients is limited to patients in whom EN is not possible or contraindicated. Early versus delayed EN, nasogastric versus nasojejunal tube for EN, EN versus PN in SAP patients and the role of immunonutrition (IN) in SAP patients are discussed in this review.