Unrecognized necrosis at same admission cholecystectomy for pancreatitis increases organ failure and infected necrosis

BACKGROUND AND AIMS

Guidelines recommend same admission cholecystectomy (SAC) in the management of mild acute gallstone pancreatitis (AGP) with a recent randomized trial supporting this recommendation. However, the push for early cholecystectomy will lead a subset of patients with evolving, unrecognized necrotizing pancreatitis (NP) to undergo laparoscopic cholecystectomy (LC) with unknown consequences. With concerns about potentially serious outcomes, we studied the outcomes in patients with unrecognized NP who underwent SAC and identified predictors of unrecognized NP at the time of SAC.

METHODS

Retrospective study of patients who appeared to have mild AGP but subsequently discovered to have unrecognized NP after SAC (study group). Outcomes were compared to a similar cohort with necrotizing AGP who did not undergo SAC (control group 1). Predictors for unrecognized NP at the time of SAC were identified through logistic regression using a second control group with truly mild AGP undergoing SAC.

RESULTS

Patients in the study group (N = 46) undergoing SAC demonstrated higher rates of persistent organ failure (p = 0.0003), infected necrosis (p = 0.02), and length of hospital stay (p = 0.049) compared to a similar group (N = 48) with necrotizing AGP who did not undergo SAC. Persistent SIRS (p < 0.0001) and WBC >12 × 10⁹/L (p < 0.0001) on the day of cholecystectomy were associated with evolving/unrecognized NP.

CONCLUSIONS

Unrecognized NP at the time of SAC is associated with increased rates of subsequent persistent organ failure, infected necrosis, and length of hospital stay. Persistent leukocytosis and SIRS at the time of proposed cholecystectomy are predictive of unrecognized NP and should prompt contrast enhanced CT prior to proceeding with LC.

Predictors and outcomes of moderately severe acute pancreatitis - Evidence to reclassify

BACKGROUND/OBJECTIVES

After the creation of the moderately severe acute pancreatitis (MSAP) category in the Revised Atlanta Classification in 2012, predictors to identify these patients early have not been identified. The MSAP category includes patients with (peri)pancreatic necrosis, fluid collections, and transient organ failure in the same category. However, these outcomes have not been studied to determine whether they result in similar outcomes to merit inclusion in the same severity.

METHODS

Retrospective, review of 514 consecutive, direct admissions for acute pancreatitis from 2010 to 2013. Multivariate logistic regression identified predictors of MSAP.

RESULTS

Persistent SIRS was the best prognostic marker of MSAP with AUC 0.72. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for persistent SIRS to predict MSAP are: 55%, 88%, 40%, 93%, and 84%. Patients with necrosis had significantly longer length of stay (LOS) (p = 0.0001) and higher rates of ICU admission (p = 0.02) compared with patients with transient organ failure. Compared to those with acute fluid collections, patients with necrosis had longer LOS (p < 0.0001), higher rates of ICU admission (p = 0.0005), required more interventions (p = 0.001), and demonstrated higher mortality (0.003).

DISCUSSION

Moderately severe pancreatitis can be distinguished from mild pancreatitis on the basis of persistent SIRS but cannot be accurately distinguished from severe pancreatitis in the first 48 h (Peri)pancreatic necrosis demonstrates significantly more morbidity compared to the other components of MSAP of fluid collections and transient organ failure.

Safety of Deep Enteroscopy and Capsule Endoscopy in LVAD Patients: Case Report and Literature Review

Patients with a left ventricular assist device (LVAD) have increased risk of gastrointestinal (GI) bleeding. They are prone to develop angiodysplasia of the small intestine, and have a higher risk of bleeding as these patients are all required to be on permanent therapeutic anticoagulation. Here we report a case of a critically ill 55-year-old male on pressors and inotropes with an LVAD, who successfully underwent an antegrade double balloon enteroscopy (DBE).