Association between neutrophil to high-density lipoprotein cholesterol ratio and disease severity in patients with acute biliary pancreatitis

BACKGROUND

The neutrophil to high-density lipoprotein cholesterol ratio (NHR) is independently associated with the severity of various diseases. However, its association with acute biliary pancreatitis (ABP) remains unknown.

METHODS

This study included 1335 eligible patients diagnosed with ABP from April 2016 to December 2022. Patients were divided into low- and high-NHR level groups using an optimal cut-off value determined utilizing Youden's index. Multivariate logistic regression analysis was used to investigate the correlation between NHR and ABP severity. Multivariate analysis-based limited restricted cubic spline (RCS) method was used to evaluate the nonlinear relationship between NHR and the risk of developing moderate or severe ABP.

RESULTS

In this study, multivariate logistic regression analysis indicated an independent association between NHR and ABP severity (p < .001). The RCS analysis showed a linear correlation between NHR and the risk of developing moderate or severe ABP (P for non-linearity > 0.05), and increased NHR was found to be independently associated with a more severe form of the disease.

CONCLUSIONS

Our study suggests that NHR is a simple and practical independent indicator of disease severity, serving as a potential novel predictor for patients with ABP.

Association between serum triglyceride level and severity of acute biliary pancreatitis

BACKGROUND

Acute biliary pancreatitis (ABP) is the most common type of acute pancreatitis. However, the effect of serum triglyceride (TG) levels on the severity of ABP remains unclear. The aim of this study was to assess the correlation between serum TG levels and the severity of ABP.

METHODS

Data from 526 ABP patients was analyzed in this study. The patients were divided into normal and elevated groups according to the TG level measured within 24 h after admission, and the elevated group was further divided into mild, moderate, and severe elevated groups. The demographic data and clinical outcomes of each group were compared.

RESULTS

Of the 526 ABP patients, 394 were in the normal TG group and 132 were in the elevated TG group (36 mild, 57 moderate, and 39 severe). The elevated group was younger (51.5 ± 12.9 vs. 58.9 ± 13.9), predominantly male (66.7% vs. 45.2%), had more history of diabetes (22.7% vs. 12.4%) and hyperlipidemia (19.7% vs. 0.8%), and developed systemic inflammatory response syndrome (SIRS) (25.8% vs. 15.5%), persistent organ failure (POF) (11.4% vs. 2.8%), and local complications (62.9% vs. 42.1%) more frequently compared to the normal group (P < 0.05). The incidence of SIRS, POF, acute peripancreatic fluid collection (APFC), and acute necrotic collection (ANC) increased with increasing TG levels (Ptrend < 0.05). In multivariate analysis, TG was independently associated with POF, APFC, and ANC in increments of 100 mg/dl (P < 0.05), and there was a linear relationship between TG levels and POF, APFC, and ANC (non-linear P > 0.05, P overall <0.05). In addition, nonalcoholic fatty liver disease is not a risk factor for POF, ANC, and APFC in ABP patients.

CONCLUSIONS

Elevated serum TG levels were independently associated with more severe ABP. The incidence of POF, APFC, and ANC in ABP patients increased with the increase of TG levels, with a linear relationship.

Clinical characteristics of three distinct types of pancreatitis with overlapping etiologies: A ten-year retrospective cohort study

BACKGROUND

Hypertriglyceridemia (HTG) is frequently observed in non-HTG-induced acute pancreatitis (AP), such as in the early stage of acute biliary pancreatitis (ABP). There is overlap in the etiologies of ABP, HTG-AP, and biliary-hypertriglyceridemia acute pancreatitis (BHAP), which may be perplexing for clinicians.

METHODS

We retrospectively analyzed 394 AP patients. The patients were divided into three groups based on etiology. We analyzed the differences among the three groups of patients in terms of general information, laboratory parameters, and prognosis.

RESULTS

The mean age of patients in the ABP group was significantly higher than that in the HTG-AP and BHAP groups (p < 0.001). Females made up a greater percentage of the ABP group, whereas males made up the majority in the HTG-AP and BHAP groups. The ABP group had the highest PCT, AMS, LPS, ALT, AST, GGT, TBIL, DBIL, APACHE II, and BISAP scores. TG and BMI were highest in the HTG-AP group. AST and GGT levels were substantially greater in BHAP patients than those in HTG-AP. The BHAP group had the greatest incidence of organ failure, systemic complications, and local complications.

CONCLUSION

ABP usually develops in people aged 50-59 years. HTG-AP primarily affects people aged 30-39 years. However, the peak incidence age of BHAP falls between the two aforementioned age groups (40-49 years). We also found that patients with BHAP seem to be in an intermediate state in terms of some biochemical markers and demographic characteristics. Furthermore, BHAP may have the worst clinical outcomes compared with HTG-AP and ABP.

Acute pancreatitis: It can be the first sign of silent gallstones

Objectives

The management of asymptomatic cholelithiasis is controversial. Silent gallstones are generally assumed to cause complications after at least one episode of biliary colic. The ratio of those silent stones that had initially caused, -or were diagnosed as the etiological agent of- acute pancreatitis has not been reported in the literature yet. Our study was designed to investigate the ratio of asymptomatic cholelithiasis in acute biliary pancreatitis cases.

Material and Methods

One hundred and seventy-one patients of 305 cases, who were followed up with the diagnosis of acute biliary pancreatitis, were identified retrospectively. Demographic specifications, laboratory findings and clinical progressions of the patients were inspected. Clinical histories were detailed by phone calls. Gallstones were radiologically detected in 85 out of 171 cases. Those patients were divided as symptomatic and asymptomatic. Clinical findings and follow-ups were evaluated by "Chi-square" test.

Results

In the study group, 80% of the patients were asymptomatic (n= 68) and 16.47% of the patients (n= 14) had complicated pancreatitis. Regarding the severity of the clinical course, being symptomatic or not was not identified as a significant factor (p= 0.108). In regard of creating symptoms, the size of the stone was not significant (p= 0.561) and obtained no prediction about the clinical severity of the pancreatitis (p= 0.728).

Conclusion

Asymptomatic cholelithiasis patients had a major percentage in acute biliary pancreatitis cases. The "wait and see" approach should be re-evaluated for silent gallstones in prospective trials.

Values of different biochemical indices and clinical scoring systems for the assessment of acute biliary pancreatitis in a Chinese population

OBJECTIVE

To investigate values of biochemical indices and clinical scoring systems for the assessment of acute biliary pancreatitis (ABP).

METHODS

Clinical characteristics, laboratory values including procalcitonin (PCT), and radiologic examinations of all ABP patients with mild acute pancreatitis (MAP), moderately severe acute pancreatitis (MSAP), or severe acute pancreatitis (SAP) were recorded within 48 hours after the onset of acute pancreatitis. Scores of the Accuracy of Acute Physiology and Chronic Health Evaluation (APACHE) II, Bedside Index of Severity in Acute Pancreatitis (BISAP), Computed Tomography Severity Index (CTSI), Ranson, Japanese Severity Score (JSS), Pancreatitis Outcome Prediction (POP) Score and Systemic Inflammatory Response Syndrome (SIRS) score were then calculated. The area under the curve (AUC) of the Receiver Operating Characteristic (ROC) curve was used to analyze the predictive values of biochemical indexes and scoring systems for ABP severity and organ failure.

RESULTS

The percentage of patients over 60 in the SAP group was higher than in the MAP and MSAP groups. PCT had the highest value for predicting SAP (AUC = 0.84, P < 0.001) and organ failure (AUC = 0.87, P < 0.001). The AUCs of APACHE II, BISAP, JSS and SIRS for predicting severity were 0.87, 0.83, 0.82, and 0.81, respectively (all P < 0.001). As for organ failure, the AUCs were 0.87, 0.85, 0.84, and 0.82, respectively (all P < 0.001).

CONCLUSIONS

PCT has a high value for predicting ABP severity and organ failure. Among the clinical scoring systems, BISAP and SIRS are more suitable for early assessment of AP; while APACHE II and JSS are more suitable for monitoring disease progression after thorough examination.

Outcomes of delayed versus early endoscopic intervention for acute biliary pancreatitis with non-severe acute cholangitis

BACKGROUND

Despite previous studies on endoscopic interventions in patients with acute biliary pancreatitis (ABP), the optimal time to perform endoscopic retrograde cholangiopancreatography (ERCP) for ABP with non-severe acute cholangitis (AC) remains controversial.

METHODS

We performed a retrospective cohort analysis of patients with concurrent ABP and non-severe AC. The patients were divided into two groups: those who underwent ERCP ≤ 72 h after admission (early ERCP group) and those who underwent ERCP > 72 h after admission (delayed ERCP group). The primary outcomes were the technical success rate and ERCP-related complications.

RESULTS

The study involved 164 patients (early ERCP, n = 70; delayed ERCP, n = 94) who were treated from 1 December 2 to 2016 to 12 December 2021. The patients' baseline characteristics were not significantly different between the two groups. The technical success rate of ERCP was similar between the two groups (94.29% vs. 97.87%, p = 0.43). Morbidity was also similar between the two groups (p = 0.83). There was no significant difference in the total hospital stay (p = 0.13). However, the early ERCP group had a longer post-ERCP hospital stay (p < 0.001).

CONCLUSION

This retrospective analysis showed that delayed ERCP performed > 72 h after admission has economic and safety outcomes similar to those of early ERCP for patients with concurrent ABP and non-severe AC.

Dynamic nomogram for persistent organ failure in acute biliary pancreatitis: Development and validation in a retrospective study

BACKGROUND

Persistent organ failure (POF) increases the risk of death in patients with acute biliary pancreatitis (ABP). Currently, there is no early risk assessment tool for POF in patients with ABP.

AIMS

To establish and validate a dynamic nomogram for predicting the risk of POF in ABP.

METHODS

This was a retrospective study of 792 patients with ABP, with 595 cases in the development group and 197 cases in the validation group. Least absolute shrinkage and selection operator regression screened the predictors of POF, and logistic regression established the model (P < 0.05). A dynamic nomogram showed the model. We evaluated the model's discrimination, calibration, and clinical effectiveness; used the bootstrap method for internal validation; and conducted external validation in the validation group.

RESULTS

Neutrophils, haematocrit, serum calcium, and blood urea nitrogen were predictors of POF in ABP. In the development group and validation group, the areas under the receiver operating characteristic curves (AUROCs) were 0.875 and 0.854, respectively, and the Hosmer-Lemeshow test (P > 0.05) and calibration curve showed good consistency between the actual and prediction probability. Decision curve analysis showed that the dynamic nomogram has excellent clinical value.

CONCLUSION

This dynamic nomogram helps with the early identification and screening of high-risk patients with POF in ABP.

Cholecystectomy 7 days vs 4 weeks after mild biliary pancreatitis; looking a decrease the incidence of persistent choledocholithiasis and ERCP: A multicentric randomized clinical trial

BACKGROUND

Mild acute biliary pancreatitis (MABP) requires definitive treatment of the cholelithiasis to avoid recurrent biliary events. Recent publications recommend performing early surgery to prevent readmissions. However, an exceedingly early cholecystectomy could imply missing the presence of persistent choledocholithiasis or requiring a significant number of preoperative endoscopic retrograde cholangiopancreatographies (ERCP). This multicentre randomized clinical trial compares early surgery performed a week after MABP with delayed surgery (at 4 weeks), to compare readmission rates for recurrent biliary events and the incidence of residual choledocholithiasis between the two groups.

MATERIALS AND METHODS

A total of 198 patients with a first episode of MABP defined by the Atlanta 2012 criteria were enrolled. Randomization was done by a central study coordinator: 98 to early surgery and 100 to delayed surgery. All of them had preoperative or intraoperative imaging to exclude persistent choledocholithiasis. Laparoscopic cholecystectomy was performed by dedicated teams of experienced surgeons.

RESULTS

Early surgery reduced the rate of readmissions for biliary events before cholecystectomy by half (7.2% vs 15.8%, p = 0,058). There were no differences in the type of surgery, postoperative stay, or complications compared with delayed surgery. Choledocholithiasis was observed in 9.0% of patients in the early group and 7.7% in the delayed group (p 0,719). The preoperative or intraoperative imaging study avoided unnecessary ERCP, which was performed in only 6 (3%) patients.

CONCLUSIONS

Early cholecystectomy performed seven days after resolution of MABP had a low incidence of recurrent biliary events and complications, and was not associated with an increase in residual choledocholithiasis or need for unnecessary ERCP.

Endoscopic Interventions for the Early and Remission Phases of Acute Biliary Pancreatitis: What are the More Concrete and Practical Situations for Performing Them?

Background/Aims

The use of endoscopic intervention (EI) for acute biliary pancreatitis (ABP) remains controversial because the severity of biliary obstruction/cholangitis/pancreatitis is not reflected in the indications for early EI (EEI).

Methods

A total of 148 patients with ABP were included to investigate 1) the differences in the rate of worsening cholangitis/pancreatitis between the EEI group and the early conservative management (ECM) group, especially for each severity of cholangitis/pancreatitis, and 2) the diagnostic ability of imaging studies, including endoscopic ultrasound (EUS), to detect common bile duct stones (CBDSs) in the ECM group.

Results

No differences were observed in the rate of worsening cholangitis between the EEI and ECM groups, regardless of the severity of cholangitis and/or the existence of impacted CBDSs. Among patients without impacted CBDSs and moderate/severe cholangitis, worsening pancreatitis was significantly more frequent in the EEI group (18% vs. 4%, p=0.048). In patients in the ECM group, the sensitivity and specificity for detecting CBDSs were 73% and 98%, respectively, for EUS, whereas the values were 13% and 92%, respectively, for magnetic resonance cholangiopancreatography.

Conclusions

EEI should be avoided in the absence of moderate/severe cholangitis and/or impacted CBDSs because of the high rate of worsening pancreatitis. EUS can contribute to the accurate detection of residual CBDSs, for the determination of the need for elective EI.

Acute biliary pancreatitis has better outcomes but increased resource utilization compared to acute alcohol-induced pancreatitis: insights from a nationwide study

Background

The differences in outcomes between acute biliary pancreatitis (ABP) and acute alcohol-induced pancreatitis (AAP) have not been well studied. We sought to examine the differences between ABP and AAP as regards to in-hospital outcomes and resource utilization, using a large nationwide database.

Methods

We queried the National Inpatient Sample databases 2016 and 2017 using the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) coding system to identify the patients with a primary diagnosis of AAP and ABP. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were hospital length of stay (LOS), hospitalization charge/cost, shock, acute kidney injury (AKI), intensive care unit (ICU) admission, and home discharge. Analysis was performed with STATA software.

Results

There was no significant difference in mortality between patients with AAP and ABP (0.42% vs. 0.82%, adjusted odds ratio [aOR] 0.95, 95% confidence interval [CI] 0.69-1.31; P=0.79). Patients with ABP had a significantly longer LOS (+0.48 days, P<0.001). Patients with ABP had significantly higher adjusted mean hospitalization charges ($+19,958, P<0.001) and costs ($+4,848, P<0.001). Patients with ABP had a significantly lower likelihood of shock (aOR 0.75, 95%CI 0.59-0.95; P=0.02), AKI (aOR 0.76, 95%CI 0.71-0.82; P<0.001) or ICU admission (aOR 0.74, 95%CI 0.62-0.88; P=0.001). They were more likely to be discharged home (aOR 1.26, 95%CI 1.18-1.34; P<0.001).

Conclusion

Although there was no difference in all-cause mortality, patients with ABP had better hospitalization outcomes but greater resource utilization.

Immediate feeding tolerance in patients with mild acute biliary pancreatitis

ANTECEDENTES

La pancreatitis aguda leve es una inflamación local del páncreas sin complicaciones locales ni falla orgánica. Su manejo consiste en tres elementos básicos: hidratación, analgesia y ayuno. La realimentación se inicia cuando el paciente no tiene dolor y refiere apetito, pero el momento exacto para iniciarla no está previamente documentado.

OBJETIVO

Determinar la tolerancia a la alimentación oral inmediata (8 horas posterior al inicio del manejo) en comparación con la alimentación temprana (48 horas) en los pacientes con pancreatitis aguda biliar leve.

MÉTODO

Se incluyeron pacientes con pancreatitis aguda biliar leve y se aleatorizaron en dos grupos: A) alimentación temprana a las 48 horas (30 pacientes) y B) alimentación inmediata a las 8 horas de inicio del manejo (29 pacientes). Fueron evaluados por un tercer observador ciego (no involucrado en el estudio) para documentar síntomas como náusea, vómito, reactivación del dolor abdominal, síndrome de respuesta inflamatoria sistémica, tolerancia alimentaria y estancia hospitalaria.

RESULTADOS

No se encontraron diferencias significativas entre los grupos en cuanto a datos clínicos y bioquímicos. La estancia hospitalaria disminuyó significativamente en el grupo B (5.4 vs. 7.8 días; p < 0.003).

CONCLUSIÓN

La alimentación inmediata en las primeras 8 horas del manejo de los pacientes con pancreatitis aguda biliar leve es bien tolerada y segura, y reduce la estancia hospitalaria.

BACKGROUND

Mild acute pancreatitis is defined as pancreatic edema, without organic failure and without local complications. Its management consists in three basic elements: hydration, analgesia and fasting. Start refeeding when the patient haven´t pain and referring hungry, but exact time for this is not previously documented.

OBJECTIVE

To determine the tolerance to immediate oral feeding (8 hours after the start of management) compared to early feeding (48 hours) in patients with mild acute biliary pancreatitis.

METHOD

Included all patient with mild acute biliary pancreatitis, and they were randomized in to two groups: A) early oral feeding (n = 30) and B) immediate oral feeding (n = 29). They were evaluated by a third blind observer (not involved in the study) for documented symptoms like nausea, vomiting, reactivation of abdominal pain, systemic inflammatory response syndrome, food tolerance and hospital stay.

RESULTS

There were no significant differences between both groups in the clinical data or in the biochemical studies. The hospital stay was significantly less in the group B (5.4 vs. 7.8 days; p < 0.003).

CONCLUSION

Immediate oral feeding is well tolerated and secure in patients with mild acute biliary pancreatitis.

ERCP is more challenging in cases of acute biliary pancreatitis than in acute cholangitis - Analysis of the Hungarian ERCP registry data

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an important therapeutic modality in acute biliary pancreatitis (ABP) cases with cholangitis or ongoing common bile duct obstruction. Theoretically, inflammation of the surrounding tissues would result in a more difficult procedure. No previous studies examined this hypothesis.

OBJECTIVES

ABP and acute cholangitis (AC) without ABP cases were compared to assess difficulty of ERCP.

METHODS

The rate of successful biliary access, advanced cannulation method, adverse events, cannulation and fluoroscopy time were compared in 240 ABP cases and 250 AC cases without ABP. Previous papillotomy, altered gastroduodenal anatomy, and cases with biliary stricture were excluded.

RESULTS

Significantly more pancreatic guidewire manipulation (adjusted odds ratio (aOR) 1.921 [1.241-2.974]) and prophylactic pancreatic stent use (aOR 4.687 [2.415-9.098]) were seen in the ABP than in AC group. Average cannulation time in the ABP patients (248 vs. 185 s; p = 0.043) were longer than in AC cases. No difference was found between biliary cannulation and adverse events rates.

CONCLUSION

ERCP in ABP cases seem to be more challenging than in AC. Difficult biliary access is more frequent in the ABP cases which warrants the involvement of an experienced endoscopist.

Optimizing cholecystectomy time in moderate acute biliary pancreatitis: A randomized clinical trial study

Background

In mild to moderate gallstone pancreatitis, cholecystectomy is the most appropriate treatment for prevention of further biliary attacks. However, the timing of cholecystectomy is not precisely determined. The present study was conducted to compare outcomes of very early (within 48 h) versus delayed (more than 1 week) laparoscopic cholecystectomy in patients with acute biliary pancreatitis (ABP).

Methods

This randomized clinical trial study was conducted in Shahid Beheshti Hospital of Kashan University of Medical Sciences from September 2016 to Mar 2019. Two hundred and eight cases with mild to moderate ABP were randomly assigned to 2 groups, with 104 patients in group 1 (operation within 48 h) and 104 in group 2 (operation after one week). Age, sex, biochemical parameters, clinical manifestation at the time of admission, operation time, recurrent biliary problems, relapse, peri-operative complications, conversion rate, and hospital length of stay in the two groups were recorded and compared. In addition, Ranson's score and Revised Atlanta criteria, the American Society of Anaesthesiologists Physical Status ASA-PS, Charlson Co-Morbidity Index (CCI), complexity of surgery and Clavien-Dindo score were also determined.

Results

There were no differences in demographics, peri-operative complications 4 (4%) vs. 4 (4%), P = 1), conversion rate (10.6% vs. 11.5%; P = 0.825) and procedure time (83 vs. 81 minutes, P = 0.110) between the two groups. There were no deaths in either group; however, the length of hospital stay was shorter in the early group compared to the delayed one, (3.66 ± 1.12 vs. 10.35 ± 1.76, P < 0.001).

Conclusion

Cholecystectomy within 48 h decreases significantly the length of hospital stay, without any difference in conversion rate, procedure time, or complication rate.

Progress in research of liver injury induced by acute biliary pancreatitis

Acute biliary pancreatitis (ABP) not only causes acute inflammation of the pancreas, but also leads to obstruction or infection of the biliary system. Liver injury is one of the most common complications of ABP. The pathological mechanisms mainly include infection and endotoxin, cholestasis, pancreatic enzyme damage, microcirculatory disorders, and oxidative stress, and the research conclusions are mostly derived from animal experiments. On the basis of routine medical treatment of ABP, active anti-infective treatment and rapid relief of biliary obstruction can promote the recovery of ABP-related liver injury.

The impact of empiric endoscopic biliary sphincterotomy on future gallstone-related complications in patients with non-severe acute biliary pancreatitis whose cholecystectomy was deferred or not performed

BACKGROUND

Early cholecystectomy (EC) is recommended in patients with acute biliary pancreatitis (ABP). In real-life practice, cholecystectomy is frequently deferred due to various reasons and delayed cholecystectomy (DC) is performed instead. Endoscopic sphincterotomy (ES) is an alternative to prevent recurrent pancreatitis, however other gallstone-related complications (GCs) may still develop. We aimed to determine the impact of ES on future GCs in patients with non-severe acute biliary pancreatitis whose cholecystectomy was deferred or not performed.

METHODS

During 2006-2016, we included patients with non-severe ABP while those with severe pancreatitis and concurrent cholangitis were excluded. GC events were compared between those who had DC with ES and those who had DC without ES. A similar comparison was made in patients with and without ES who did not receive cholecystectomy.

RESULTS

Of 266 patients with ABP, non-severe ABP was identified in 146. Only 16 (11%) had EC. Of patients with non-severe ABP who underwent DC (n = 88), recurrent ABP in the ES group was lower than those from the non-ES group (2% vs. 17%; p = 0.01). Acute cholecystitis was found in 0%, 6% and 10% of patients with EC, DC and those without cholecystectomy (p = 0.39). Of those who did not undergo cholecystectomy (n = 42), recurrent ABP in the ES group was still lower than the non-ES group (4% vs. 36%; p = 0.006). ES related complications were mild pancreatitis (4%) and post sphincterotomy bleeding (5%).

CONCLUSIONS

In patient with non-severe ABP, ES is an alternative to reduce recurrent ABP, however without EC, future cholecystitis may still develop.

Feasibility of Temporary Pancreatic Stenting after Early Endoscopic Retrograde Cholangiopancreatography in Patients with Acute Biliary Pancreatitis

Background/Aims

To assess the safety and effectiveness of temporary pancreatic stenting after early endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis regardless of the severity or concomitant cholangitis.

Methods

Temporary pancreatic stenting was performed in 79 patients with visualized pancreatic duct during ERCP. The outcomes of 64 patients with adequate pancreatic stenting (PS) and 15 patients with inadequate pancreatic stenting (no PS) were compared in this prospective, observational trial.

Results

The baseline characteristics were similar. Development of systemic inflammatory response syndrome (7.8% for PS vs. 13.3% for no PS; p=0.50) and mortality (none for both groups; p=0.99) did not differ. However, fewer local complications occurred in PS than in no PS (4.7% for PS vs. 20.0% for no PS; p=0.04) and the difference was most outstanding in necrosis (1.6% for PS vs. 13.3% for no PS; p=0.03).

Conclusions

Temporary pancreatic stenting after early ERCP should be considered safe, as complications did not increase even in cases of inadequate stenting. However, if successful, there appears to be a reduction in local complications.

Acute biliary pancreatitis in cholecystectomised patients

OBJECTIVE:

The present study is an evaluation of cases of acute biliary pancreatitis that developed subsequent to cholecystectomy.

METHODS:

Total of 44 patients were assessed in this retrospective study. Demographic characteristics, severity of illness, time elapsed between cholecystectomy and development of pancreatitis, whether endoscopic sphincterotomy (ES) was performed, surgical procedure used, duration of hospitalization, and mortality data were recorded.

RESULTS:

Mean age of all patients was 60.14±16.4 years (range: 20–85 years), and female:male ratio was 28:16. Mean length of time elapsed between cholecystectomy and development of acute pancreatitis was 80.6 months (range: 5–230 months). Gallstones and biliary sand were found in the choledochi of 36 patients upon endoscopic retrograde cholangiopancreatography (ERCP), but not observed in the remaining 8 patients. ES was performed and material was extracted in 32 of the 36 patients, but stone extraction was unsuccessful in 4 cases; 3 patients underwent open surgery with choledochus exploration and 1 patient died. Excluding this patient, mean duration of hospitalization was 7.5±2.5 days.

CONCLUSION:

Stones in bile ducts may remain asymptomatic for long periods after cholecystectomy. However, some stones trigger acute pancreatitis months or years after cholecystectomy, causing risk of mortality. ERCP and ES are the standard treatments. If these are unsuccessful, the choledochus may be explored via open or laparoscopic surgery.

Role of intraoperative cholangiography for detecting residual stones after biliary pancreatitis: still useful? A retrospective study

Background

Intraoperative cholangiography (IOC) may detect residual stones in the common bile duct (CBD) after acute biliary pancreatitis (ABP). The aim of the present study is to analyze the utility of IOC in detecting residual stones in patients undergoing cholecystectomy for ABP and if complications are related with this procedure.

Methods

Demographic and clinical factors were assessed in patients with mild ABP who underwent IOC during laparoscopic cholecystectomy. Factors assessed included preoperative size of the CBD on ultrasonography, presence of stones in the gallbladder and the CBD, and IOC results. For the statistical analysis, χ² or Fisher’s exact tests to compare proportions and the nonparametric Mann–Whitney U test for analysis of values with abnormal distribution were used.

Results

The study included 113 patients, 82 males (72.6%) and 31 females (27.4%), of mean age 46.9 ± 14.7 years (range 18–86 years). All preoperative laboratory indicators were elevated. The group of the patients with stones in the CBD diagnosed by IOC was divided in patients with diameters <0.8 mm and with diameters ≥0.8 mm of the CBD diagnosed preoperatively with ultrasound. The laboratory tests do not demonstrate difference statistically significative between these two groups. The group of the patients without stones in the CBD diagnosed by IOC was also divided in patients with diameters <0.8 mm and with diameters ≥0.8 mm of the CBD. Also in these two groups, the statistical analysis of the laboratory tests does not demonstrate significative difference. Most procedures were performed by specialists (64.6%), and all patients underwent IOC. IOC showed stones in 84/113 patients (74.3%). A comparison of patients with and without stones at IOC showed similar mean times from hospitalization to surgery (5.9 days [range 2–12 days] vs. 6.1 days [range 2–23 days]), from surgery until hospital discharge (2.0 days [range 0–4 days] vs. 2.2 days [range 0–11 days]), and overall length of stay (7.9 days [range 3–19 days] vs. 8.3 days [range 3–23 days]) (P > 0.001).

Conclusions

IOC is useful to diagnose residual CBD stones, without increasing complications related to the procedure itself.

Acute biliary pancreatitis: focus on recurrence rate and costs when current guidelines are not complied

BACKGROUND

International guidelines recommend cholecystectomy within 2-4 weeks after mild to moderate acute biliary pancreatitis (ABP) to prevent recurrence. We aimed to investigate the compliance to guidelines concerning early cholecystectomy and the associated costs.

METHODS

Admissions for ABP 2011-2013 were retrospectively reviewed. Classification was made according to the revised Atlanta classification. Treatment, time to surgery and recurrence, as well as cost analysis for both in-hospital costs and loss of production (LOP) were performed.

RESULTS

In total, 254 patients were included. Some 202 of the ABP patients (80%) underwent definitive treatment during their first attack of ABP (68% cholecystectomy, 17% endoscopic retrograde cholangiopancreatography (ERCP), 15% both interventions) and 186 (73%) were treated within 1 month of discharge. Patients with ERCP alone were significantly older than cholecystectomy cases (p < .001), but no significant difference was observed between those who underwent ERCP or no treatment (p = .071). Mild ABP had intervention earlier (p < .001). In all, 52 patients (20%) had no intervention, out of which 15 were readmitted due to pancreatitis, compared to 3 patients of those treated at the initial admission (p < .001). The mean cost for hospital care and LOP in mild ABP was €6882 ± 3010 and €9580 ± 7047 for moderate ABP (p = .001). The cost for a recurrent episode was €16,412 ± 22,367.

CONCLUSION

By improved compliance to current guidelines concerning the management of ABP, recurrence rate and associated costs can potentially be reduced.

Comparative analysis of early surgery and conservative treatment for acute gallstone pancreatitis

AIM: To explore the clinical curative effect and safety between surgical treatment and conservative treatment for acute biliary pancreatitis (ABP) due to choledocholithiasis.

METHODS: A total of 119 ABP (including severe ABP) patients received either conservative treatment (n = 43) or surgical treatment (n = 54). Laboratory indexes, complications as well as hospitalization time were comparatively analyzed between the two groups.

RESULTS: Compared with the conservative treatment group, times to recovery of urine amylase and blood amylase and the average length of hospital stay were significantly lower in the surgical treatment group (6.5 d ± 3.2 d vs 8.3 d ± 4.3 d, 7.3 d ± 4.2 d vs 10.2 d ± 3.7 d, 15.2 d ± 4.3 d vs 18.3 d ± 5.5 d, P < 0.05). There were 5 cases of complications in the surgical treatment group and 7 cases in the conservative treatment group (P > 0.05).

CONCLUSION: Early surgical treatment for ABP, especially acute cholangitis, is safe and effective.

Does Endoscopic Sphincterotomy and/or Cholecystectomy Reduce Recurrence Rate of Acute Biliary Pancreatitis?

BACKGROUND/AIMS

Practice guidelines from international societies have recommended cholecystectomy during the same hospitalization for acute biliary pancreatitis (ABP). The aim of this study is to investigate the question of whether endoscopic sphincterotomy (EST) and/or cholecystectomy during the same hospitalization can reduce the recurrence rate of ABP.

METHODS

A total of 119 patients with ABP admitted to our institution between May 2005 and May 2010 who had complete follow-up data until May 2012 were enrolled.

RESULTS

No significant differences in initial CT severity index and Charlson comorbidity index were observed between EST (n = 64) and non-EST group (n = 55) and among subgroups classified according to interventions performed. In Kaplan-Meier analyses, significantly higher recurrence rates of ABP were observed in the non-EST group compared to the EST group (p <œ 0.01), and in the conservative treatment group compared to other intervention groups (p <œ 0.01). The frequency of complications from ABP was significantly higher in the conservative treatment group (35.7%) and lowest in the EST plus cholecystectomy group (5.0%, p = 0.008). In multivariate analysis, conservative treatment without EST and/or cholecystectomy, and non-EST group were independent risk factors for recurrence after the initial attack of ABP.

CONCLUSIONS

ERCP with EST and cholecystectomy during the index admission is associated with reduced recurrence rates of ABP.

Role and timing of endoscopy in acute biliary pancreatitis

The role and timing of endoscopy in the setting of acute biliary pancreatitis (ABP) is still being debated. Despite numerous randomized trials have been published, there is an obvious lack of consensus on the indications and timing of endoscopic retrograde cholangiopancreatography (ERCP) in ABP in meta-analyses and nationwide guidelines. The present editorial has been written to clarify the role of endoscopy in ABP. In clinical practice the decision to perform an ERCP is often based on biochemical and radiological criteria despite they already have been shown to be unreliable predictors of common bile duct stone presence. Endoscopic ultrasonography (EUS) is not currently a worldwide standard diagnostic procedure early in the course of acute biliary pancreatitis, but it has been shown to be accurate, safe and cost effective in diagnosing biliary obstructions compared with magnetic resonance cholangiopancreatography and ERCP and therefore in preventing unnecessary ERCP and its related complications. Early EUS in ABP allows, if appropriate, immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.

Early endoscopic ultrasonography in acute biliary pancreatitis: A prospective pilot study

AIM: To investigate the clinical usefulness of early endoscopic ultrasonography (EUS) in the management of acute biliary pancreatitis (ABP).

METHODS: All consecutive patients entering the emergency department between January 2010 and December 2012 due to acute abdominal pain and showing biochemical and/or radiological findings consistent with possible ABP were prospectively enrolled. Patients were classified as having a low, moderate, or high probability of common bile duct (CBD) stones, according to the established risk stratification. Exclusion criteria were: gastrectomy or patient in whom the cause of biliary obstruction was already identified by ultrasonography. All enrolled patients underwent EUS within 48 h of their admission. Endoscopic retrograde cholangiopancreatography was performed immediately after EUS only in those cases with proven CBD stones or sludge. The following parameters were investigated: (1) clinical: age, sex, fever; (2) radiological: dilated CBD; and (3) biochemical: bilirubin, AST, ALT, gGT, ALP, amylase, lipasis, PCR. Association between presence of CBD stone at EUS and the individual predictors were assessed by univariate logistic regression. Predictors significantly associated with CBD stones (P < 0.05) were entered in a multivariate logistic regression model.

RESULTS: A total of 181 patients with pancreatitis were admitted to the emergency department between January 2010 and December 2012. After exclusion criteria a total of 71 patients (38 females, 53.5%, mean age 58 ± 20.12 years, range 27-89 years; 33 males, 46.5%, mean age 65 ± 11.86 years, range 41-91 years) were included in the present study. The probability of CBD stones was considered low in 21 cases (29%), moderate in 26 (37%), and high in the remaining 24 (34%). The 71 patients included in the study underwent EUS, which allowed for a complete evaluation of the target sites in all the cases. The procedure was completed in a mean time of 14.7 min (range 9-34 min), without any notable complications.The overall CBD stone frequency was 44% (31 of 71), with a significant increase from the group at low pretest probability to that at moderate (OR = 5.79, P = 0.01) and high (OR = 4.25, P = 0.03) pretest probability.

CONCLUSION: Early EUS in ABP allows, if appropriate, immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.

Application of triple nutrition support in acute biliary pancreatitis patients with liver injury

AIM: To evaluate the effect of the usage of glutathione, Dachengqi decoction and omega-3 polyunsaturated fatty acid in acute biliary pancreatitis (ABP) patients with liver injury.

METHODS: Seventy-one hospitalized patients were randomly divided into either a control group (n = 35) or a study group (n = 36). All patients received routine treatments which included oxygen uptake, fasting, gastrointestinal decompression, inhibition of pancreatic secretion and pancreatic enzyme activity, regulation of fluid, electrolytes and acid-base balance, use of antibiotics, and protecting the function of major organs. The two groups were both given parenteral nutrition with an energy of 20-25 kcal/(kg•d), a ratio of nitrogen to calorie of 1:(156.25-178.57), and a ratio of carbohydrate to fat of (50-60%):(40-50%). Fat was supported by 20% medium chain/long chain triglycerides in the control group, and by omega-3 polyunsaturated fatty acids in the study group. Meanwhile, glutathione (1200 mg/d) and Dachenqi decoction were used in the study group. Indexes of liver function, inflammatory factors and oxidative stress injury were compared for the two groups.

RESULTS: There was a significant difference in alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), gamma glutamyl transpeptidase (GGT), total bilirubin (TB), direct bilirubin (DB), triglyceride (TG), tumor necrosis factor (TNF)-α, interleukin (IL)-2, IL-6, superoxide dismutase (SOD) and methane dicarboxylic aldehyde (MDA) between the two groups (P < 0.05), all of which favored the study group.

CONCLUSION: During nutrition treatment of ABP, preventing liver injury is very important. Glutathione combined with omega-3 polyunsaturated fatty acid and Dachengqi decoction can improve liver function, inflammatory factors and oxidative stress injury, and thereby reduce the incidence rate of liver injury in ABP patients.

Emodin protects from deoxycholic acid-induced AR42J cell damage

AIM: To investigate whether emodin exerts a protect effect against deoxycholic acid (DCA)-induced cell damage in rat pancreatic acinar cell line AR42J.

METHODS: AR42J cells were divided into five groups: normal control cells, cells treated with 0.4 or 0.8 mmol/L DCA, and those treated with 0.4 or 0.8 mmol/L DCA plus emodin (20 mg/L). The rates of apoptosis and necrosis were detected by flow cytometry and AV/PI double staining. The activity of amylase in the medium and cytoplasm was determined.

RESULTS: DCA at a dose of 0.4 mmol/L mainly induced the apoptosis of AR42J cells, while 0.8 mmol/L of DCA induced the necrosis of AR42J cells. Emodin significantly reduced DCA-induced late apoptosis (27.9% vs 34.1%) and necrosis (38.1% vs 45.4%), but did not significantly change the activity of amylase in the medium and cytoplasm of AR42J cells.

CONCLUSION: Emodin has some protective effects against DCA-induced AR42J cell damage, but does not influence amylase synthesis and secretion by acinar cells.

Role of endoscopic ultrasound during hospitalization for acute pancreatitis

Endoscopic ultrasound (EUS) is often used to detect the cause of acute pancreatitis (AP) after the acute attack has subsided. The limited data on its role during hospitalization for AP are reviewed here. The ability of EUS to visualize the pancreas and bile duct, the sonographic appearance of the pancreas, correlation of such appearance to clinical outcomes and the impact on AP management are analyzed from studies. The most important indication for EUS appears to be for detection of suspected common bile duct and/or gall bladder stones and microlithiasis. Such an approach might avoid diagnostic endoscopic retrograde cholangio-pancreatography with its known complications. The use of EUS during hospitalization for AP still appears to be infrequent but may become more frequent in future.

Role of pancreatic endoscopic ultrasonography in 2010

Endoscopic ultrasonography (EUS) was introduced 25 years ago aiming at better visualization of the pancreas compared to transabdominal ultrasonography. This update discusses the current evidence in 2010 concerning the role of EUS in the clinical management of patients with pancreatic disease. Major indications of EUS are: (1) Detection of common bile duct stones (e.g. in acute pancreatitis); (2) Detection of small exo- and endocrine pancreatic tumours; and (3) Performance of fine needle aspiration in pancreatic masses depending on therapeutic consequences. EUS seems to be less useful in cases of chronic pancreatitis and cystic pancreatic lesions. Moreover the constant improvement of computed tomography has limited the role of EUS in pancreatic cancer staging. On the other hand, new therapeutic options are available due to EUS, such as pancreatic cyst drainage and celiac plexus neurolysis, offering a new field in which new techniques may arise. So the main goal of this review is to determine the exact role of EUS in a number of pancreatic and biliary diseases.

Endoscopic treatment of acute biliary pancreatitis: a systematic review

AIM: To assess the efficacy and safety of endoscopic treatment of acute biliary pancreatitis (ABP).

METHODS: Relevant databases were searched to identify randomized controlled trials or quasi-randomized controlled trials evaluating the efficacy and safety of endoscopic treatment of acute biliary pancreatitis. The quality of the included studies was evaluated using the criteria recommended by the Cochrane Handbook for Systematic Reviews of Interventions Version 5.0. Statistical analyses were performed with RevMan5.0 (Cochrane Collaboration) software.

RESULTS: Four randomized controlled trials or quais-randomized controlled trials involving 317 patients were included. A meta-analysis showed that there were significant differences, between endoscopic treatment group and conventional treatment group, in the time to onset of abdominal pain relief [odd ratio (OR) = -2.98; 95% confidence interval (CI): -4.98, -0.97], the time to recovery of white blood cells (OR = -4.63, 95%CI: -5.29, -3.97) and serum amylase (OR = -3.85; 95%CI: -4.49, -3.21), the complication rate (OR = 0.34; 95%CI: 0.18, 0.66), and the hospitalization time (OR = -7.51; 95%CI: -9.89, -5.13).

CONCLUSION: Current evidence shows that endoscopic treatment of acute biliary pancreatitis can significantly reduce the time to onset of abdominal pain relief, the time to recovery of white blood cells and serum amylase, the complication rate, and the hospitalization time.

Cytotoxic effects of different bile acids on pancreatic acinar AR42J cells

AIM: To investigate the cytotoxic effects of seven different bile acids on pancreatic acinar AR42J cells by detecting the survival, necrosis and apoptosis of AR42J cells incubated with different bile acids.

METHODS: The effects of different bile acids on the survival of rat AR42J cells were detected by methyl thiazolyl tetrazolium (MTT) assay. Cell morphological changes were observed by microscopy and fluorescence microscopy. Cell apoptosis and necrosis were determined by annexin-V and propidium iodide double staining and flow cytometry.

RESULTS: Cholic acid (CA), glycocholic acid (GCA), and glycodeoxycholic acid (GDCA) at doses ranging from 0.1 to 1.0 mmol/L had no cytotoxic effects on AR42J cells. Deoxycholic acid (DCA), chenodeoxycholic acid (CDCA) and lithocholic acid (LCA) at doses ≥ 0.3 mmol/L, and taurodeoxycholic acid (TDCA) at doses ≥ 0.4 mmol/L induced cytotoxic effects on AR42J cells in a dose-dependent manner. No significant differences were noted in the apoptotic rate and necrotic rate between untreated AR42J cells and those treated with 0.8 mmol/L of CA (apoptotic rate: 1.2% vs 0.9%; necrotic rate: 1.0% vs 1.0%). The apoptotic rate and necrotic rate of AR42J cells treated with 0.4 mmol/L of DCA were 45.2% and 8.9%, respectively, while those treated with 0.8 mmol/L of DCA were 18.6% and 45.4%, respectively.

CONCLUSION: Different bile acids exert different cytotoxic effects on AR42J cells. Some bile acids induce the apoptosis and/or necrosis of AR42J cells in a dose-dependent manner.

Endoscopic sphincterotomy in acute biliary pancreatitis: A question of anesthesiological risk

Two consecutive surveys of acute pancreatitis in Italy, based on more than 1000 patients with acute pancreatitis, reported that the etiology of the disease indicates biliary origin in about 60% of the cases. The United Kingdom guidelines report that severe gallstone pancreatitis in the presence of increasingly deranged liver function tests and signs of cholangitis (fever, rigors, and positive blood cultures) requires an immediate and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). These guidelines also recommend that patients with gallstone pancreatitis should undergo prompt cholecystectomy, possibly during the same hospitalization. However, a certain percentage of patients are unfit for cholecystectomy because advanced age and presence of comorbidity. We evaluated the early and long-term results of endoscopic intervention in relation to the anesthesiological risk for 87 patients with acute biliary pancreatitis. All patients underwent ERCP and were evaluated according to the American Society of Anesthesiology (ASA) criteria immediately before the operative procedure. The severity of acute pancreatitis was positively related to the anesthesiological grade. There was no significant relationship between the frequency of biliopancreatic complications during the follow-up and the ASA grade. The frequency of cholecystectomy was inversely related to the ASA grade and multivariate analysis showed that the ASA grade and age were significantly related to survival. Finally, endoscopic treatment also appeared to be safe and effective in patients at high anesthesiological risk with acute pancreatitis. These results further support the hypothesis that endoscopic sphincterotomy might be considered a definitive treatment for patients with acute biliary pancreatitis and an elevated ASA grade.

Endoscopic treatment for senile acute biliary pancreatitis: an analysis of 42 cases

AIM: To investigate the superiority of endoscopic treatment for senile acute biliary pancreatitis (ABP).

METHODS: Eighty-six ABP (including severe ABP) patients over 60 years were randomly divided into two groups receiving endoscopy (n = 42) and traditional therapy (n = 46) respectively. The therapeutic effects (Recovery time of WBC, hepatic function and hemodiastase, remission time of bellyache, hospitalization time, complication rate and death rate) were comparatively analyzed between the two groups.

RESULTS: Recovery time of WBC, hepatic function and hemodiastase were significantly shorter in endoscopic treatment group than traditional therapy group (9.7 ± 2.6 d vs 13.3 ± 3.9 d, 12.5 ± 5.1 d vs 21.3 ± 6.5 d, 8.2 ± 2.1 vs 12.5 ± 3.3 respectively, all P < 0.05), and remission time of bellyache was shorter too in endoscopic treatment group (7.7 ± 2.7 d vs 11.4 ± 3.7 d, P < 0.05). Hospitalization time was markedly shortened in treatment group (16.1 ± 5.1 d vs 23.3 ± 7.6 d, P < 0.05). The total complication rate was significantly lower in endoscopic group than traditional therapy group(12.5% vs 23.8%, P < 0.05), but no statistical significance of total death rate was observed between the two groups.

CONCLUSION: Endoscopic treatment for senile ABP is safe, effective and minimally invasive, and is recommended for wide use.

Emergency duodenoscopy for acute biliary pancreatitis: an analysis of 94 cases

AIM: To study the clinic outcomes of endoscopic naso-biliary drainage (ENBD) for acute biliary pancreatitis (ABP).

METHODS: We retrospectively analyzed 94 patients with ABP who had undergone emergency endoscopic examination and were treated with endoscopic naso-biliary drainage (ENBD) from January 2004 to December 2005. Endoscopic sphincterotomy (EST) was also carried out in some cases.

RESULTS: Ninety-one patients (96.81%) were successfully healed after emergency duodenoscopy. There were no severe complications or mortality. On average, abdominal pain symptoms recovered within 42.3 h and amylase level within 56 h. After being treated by ENBD for 1 week, the pancreatic edema in 49 of 61 cases was resolved; peripancreatic effusion was completely absorbed in 21 of 29 patients and was obviously decreased in the remaining 8, without clinical complications.

CONCLUSION: Emergency duodenoscopy is a safe and new method for treating ABP.

Clinical contrast study of endoscopic treatment for acute biliary pancreatitis

AIM: To explore the value of endoscopic treat-ment for acute biliary pancreatitis (ABP).

METHODS: A total of 119 ABP (including severe ABP) patients were treated with endoscopy (n = 40), drugs (n = 42), and operation (n = 37), respectively. The symptoms, laboratory indexes, rates of complications and deaths as well as in-hospital time were comparatively analyzed between the three groups.

RESULTS: The rates of complications and deaths were 12.5% (5/40) and 5.0% (2/40) in endoscopic treatment group, 29.7% (11/37) and 5.4% (2/37) in surgical treatment group, and 23.8% (10/42) and 7.1% (3/42) in drug treatment group, respectively. The symptoms, laboratory indexes, rates of complications and deaths as well as in-hospital time were obviously improved in comparison with those in the other two groups (P < 0.05).

CONCLUSION: Endoscopic treatment for ABP, especially SABP, is effective, safe, economical, simple and convenient, with fewer complications.

Acute biliary pancreatitis and cholecystolithiasis in a child: One time treatment with laparoendoscopic “Rendez-vous” procedure

Acute biliary pancreatitis (ABP) is rare in childhood and endoscopic sphincterotomy should be avoided in the child due to the risk of both early and late complications but, when necessary, the optimal timing between endoscopic procedure and cholecystectomy is still uncertain. A nine years old child with acute biliary pancreatitis underwent successfull laparo-endoscopic “Rendez-Vous” procedure in which endoscopic drainage of the common bile duct and laparoscopic cholecystectomy were performed simultaneously. This is the first case reported of laparo-endoscopic Rendez-Vous in a child. The excellent outcome of this patient and the review of the literature concerning other available options for the treatment of such cases suggest that this procedure offers great advantages, especially in children, of reducing the required number of treatments, the risk of ineffectiveness, the number of anaesthesia, the length of hospital stay and the risk of iatrogenic morbidity.