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Willis J, vanSonnenberg E. Updated Review of Radiologic Imaging and Intervention for Acute Pancreatitis and Its Complications. J Intensive Care Med 2024:8850666241234596. [PMID: 38414385 DOI: 10.1177/08850666241234596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
This is a current update on radiologic imaging and intervention of acute pancreatitis and its complications. In this review, we define the various complications of acute pancreatitis, discuss the imaging findings, as well as the timing of when these complications occur. The various classification and scoring systems of acute pancreatitis are summarized. Advantages and disadvantages of the 3 primary radiologic imaging modalities are compared. We then discuss radiologic interventions for acute pancreatitis. These include diagnostic aspiration as well as percutaneous catheter drainage of fluid collections, abscesses, pseudocysts, and necrosis. Recommendations for when these interventions should be considered, as well as situations in which they are contraindicated are discussed. Fortunately, acute pancreatitis usually is mild; however, serious complications occur in 20%, and admission of patients to the intensive care unit (ICU) occurs in over 10%. In this paper, we will focus on the imaging and interventional radiologic aspects for the serious complications and patients admitted to the ICU.
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Affiliation(s)
- Joshua Willis
- University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
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Beyer G, Hoffmeister A, Michl P, Gress TM, Huber W, Algül H, Neesse A, Meining A, Seufferlein TW, Rosendahl J, Kahl S, Keller J, Werner J, Friess H, Bufler P, Löhr MJ, Schneider A, Lynen Jansen P, Esposito I, Grenacher L, Mössner J, Lerch MM, Mayerle J. S3-Leitlinie Pankreatitis – Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – September 2021 – AWMF Registernummer 021-003. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:419-521. [PMID: 35263785 DOI: 10.1055/a-1735-3864] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Georg Beyer
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
| | - Albrecht Hoffmeister
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Patrick Michl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Deutschland
| | - Wolfgang Huber
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Hana Algül
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Albrecht Neesse
- Klinik für Gastroenterologie, gastrointestinale Onkologie und Endokrinologie, Universitätsmedizin Göttingen, Deutschland
| | - Alexander Meining
- Medizinische Klinik und Poliklinik II Gastroenterologie und Hepatologie, Universitätsklinikum Würzburg, Deutschland
| | | | - Jonas Rosendahl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Stefan Kahl
- Klinik für Innere Medizin m. Schwerpkt. Gastro./Hämat./Onko./Nephro., DRK Kliniken Berlin Köpenick, Deutschland
| | - Jutta Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Jens Werner
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, Deutschland
| | - Helmut Friess
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, München, Deutschland
| | - Philip Bufler
- Klinik für Pädiatrie m. S. Gastroenterologie, Nephrologie und Stoffwechselmedizin, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Deutschland
| | - Matthias J Löhr
- Department of Gastroenterology, Karolinska, Universitetssjukhuset, Stockholm, Schweden
| | - Alexander Schneider
- Klinik für Gastroenterologie und Hepatologie, Klinikum Bad Hersfeld, Deutschland
| | - Petra Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Irene Esposito
- Pathologisches Institut, Heinrich-Heine-Universität und Universitätsklinikum Duesseldorf, Duesseldorf, Deutschland
| | - Lars Grenacher
- Conradia Radiologie München Schwabing, München, Deutschland
| | - Joachim Mössner
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Markus M Lerch
- Klinik für Innere Medizin A, Universitätsmedizin Greifswald, Deutschland.,Klinikum der Ludwig-Maximilians-Universität (LMU) München, Deutschland
| | - Julia Mayerle
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
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Rahnemai-Azar AA, Sutter C, Hayat U, Glessing B, Ammori J, Tavri S. Multidisciplinary Management of Complicated Pancreatitis: What Every Interventional Radiologist Should Know. AJR Am J Roentgenol 2021; 217:921-932. [PMID: 33470838 DOI: 10.2214/ajr.20.25168] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Management of acute pancreatitis is challenging in the presence of local complications that include pancreatic and peripancreatic collections and vascular complications. This review, targeted for interventional radiologists, describes minimally invasive endoscopic, image-guided percutaneous, and surgical procedures for management of complicated pancreatitis and provides insight into the procedures' algorithmic application. Local complications are optimally managed in a multidisciplinary team setting that includes advanced endoscopists; pancreatic surgeons; diagnostic and interventional radiologists; and specialists in infectious disease, nutrition, and critical care medicine. Large symptomatic or complicated sterile collections and secondary infected collections warrant drainage or débridement. The drainage is usually delayed for 4-6 weeks unless clinical deterioration warrants early intervention. If collections are accessible by endoscopy, endoscopic procedures are preferred to avoid pancreaticocutaneous fistulas. Image-guided percutaneous drainage is indicated for symptomatic collections that are not accessible for endoscopic drainage or that present in the acute setting before developing a mature wall. Peripancreatic arterial pseudoaneurysms should be embolized before necrosectomy procedures to prevent potentially life-threatening hemorrhage. Surgical procedures are reserved for symptomatic collections that persist despite endoscopic or interventional drainage attempts. Understanding these procedures facilitates their integration by interventional radiologists into the complex longitudinal care of patients with complicated pancreatitis.
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Affiliation(s)
- Amir Ata Rahnemai-Azar
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106
| | - Christopher Sutter
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106
| | - Umar Hayat
- Department of Medicine, Division of Gastroenterology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Brooke Glessing
- Department of Medicine, Division of Gastroenterology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - John Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sidhartha Tavri
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106
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Abstract
Acute pancreatitis is the most common gastrointestinal indication for hospital admission, and infected pancreatic and/or extrapancreatic necrosis is a potentially lethal complication. Current standard treatment of infected necrosis is a step-up approach, consisting of catheter drainage followed, if necessary, by minimally invasive necrosectomy. International guidelines recommend postponing catheter drainage until the stage of 'walled-off necrosis' has been reached, a process that typically takes 4 weeks after onset of acute pancreatitis. This recommendation stems from the era of primary surgical necrosectomy. However, postponement of catheter drainage might not be necessary, and earlier detection and subsequent earlier drainage of infected necrosis could improve outcome. Strong data and consensus among international expert pancreatologists are lacking. Future clinical, preferably randomized, studies should focus on timing of catheter drainage in patients with infected necrotizing pancreatitis. In this Perspectives, we discuss challenges in the invasive treatment of patients with infected necrotizing pancreatitis, focusing on timing of catheter drainage.
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De Waele JJ, Rello J, Anzueto A, Moreno R, Lipman J, Sakr Y, Pickkers P, Leone M, Ferguson A, Oud L, Vincent JL. Infections and use of antibiotics in patients admitted for severe acute pancreatitis: data from the EPIC II study. Surg Infect (Larchmt) 2014; 15:394-8. [PMID: 24819027 DOI: 10.1089/sur.2012.228] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Infectious complications are frequent in severe acute pancreatitis (SAP) but multinational epidemiologic data are lacking. The aim of the study was to analyze the characteristics of the infectious complications and antimicrobial use in this setting. METHODS One-day point prevalence study of infection in critically ill patients (Extended Prevalence of Infection in the ICU-II study), performed in 1,265 ICUs in 75 countries. RESULTS Of the 13,796 patients in the study, 159 were admitted with SAP. One-hundred sixteen (73%) had infections: 31% intra-abdominal, 16% extra-abdominal, and 26% both. Gram-negative bacteria were more prevalent than gram-positive organisms, anaerobes, or fungi. Therapeutically, penicillins and other beta-lactams were used most frequently. Prophylactic antibiotics were administered to 24% of the patients with SAP. CONCLUSIONS Infections are frequent in patients admitted with SAP; most are intra-abdominal infections. Microbiology is diverse with gram-negative micro-organisms most frequently isolated. Most patients admitted to the ICU for SAP receive antibiotics at some point.
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Affiliation(s)
- Jan J De Waele
- 1 Department of Critical Care Medicine, Ghent Medical School and University Hospital , Ghent, Belgium
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van Baal MC, Bollen TL, Bakker OJ, van Goor H, Boermeester MA, Dejong CH, Gooszen HG, van der Harst E, van Eijck CH, van Santvoort HC, Besselink MG. The role of routine fine-needle aspiration in the diagnosis of infected necrotizing pancreatitis. Surgery 2014; 155:442-8. [DOI: 10.1016/j.surg.2013.10.001] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 10/07/2013] [Indexed: 02/07/2023]
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Dupuis CS, Baptista V, Whalen G, Karam AR, Singh A, Wassef W, Kim YH. Diagnosis and management of acute pancreatitis and its complications. GASTROINTESTINAL INTERVENTION 2013. [DOI: 10.1016/j.gii.2013.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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CT-guided percutaneous catheter drainage of acute infectious necrotizing pancreatitis: assessment of effectiveness and safety. AJR Am J Roentgenol 2012; 199:192-9. [PMID: 22733912 DOI: 10.2214/ajr.11.6984] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this study is to assess retrospectively the effectiveness and safety of CT-guided percutaneous drainage and to determine the factors influencing clinical success and mortality in patients with infectious necrotizing pancreatitis. MATERIALS AND METHODS From April 1997 to December 2005, 48 consecutive patients (33 men and 15 women; median age, 58.5 years) with proven infectious necrotizing pancreatitis underwent percutaneous catheter drainage via CT guidance. Evaluated factors included clinical, biologic, and radiologic scores; drainage and catheter characteristics; and complications. Clinical success was defined as control of sepsis without requirement for surgery. Univariate analysis was performed to determine factors that could have affected the clinical success and the mortality rates. RESULTS Clinical success was achieved in 31 of 48 patients (64.6%) and was significantly associated with Ranson score (p = 0.01) and with the delay between admission and the beginning of the drainage (p = 0.005), with a calculated threshold delay of 18 days (p = 0.001). The global mortality rate (14/48 [29%]) was also influenced by the Ranson score (p = 01) and the delay of drainage (p = 0.04) with the same threshold delay (p = 0.01). Only two major nonlethal procedure-related complications were observed. CONCLUSION Percutaneous catheter drainage is a safe and effective technique to treat acute infectious necrotizing pancreatitis.
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Zerem E. Reply to: draining sterile fluid collections in acute pancreatitis? Primum non nocere! Surg Endosc 2011; 25:979-80. [PMID: 20607555 DOI: 10.1007/s00464-010-1218-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Affiliation(s)
- Jordan R Stem
- Department of Surgery, The University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA
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Refinetti RA, Martinez R. Pancreatite necro-hemorrágica: atualização e momento de operar. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2010. [DOI: 10.1590/s0102-67202010000200013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUÇÃO: A pancreatite necro-hemorrágica representa a variante mais grave do espectro de apresentações clínicas que podem compor o quadro da pancreatite aguda. Embora já conhecida há muitos séculos, inúmeras questões permanecem em aberto acerca dessa entidade e o número de trabalhos sobre o assunto publicados nos últimos anos tem sido muito expressivo. MÉTODO: Foi realizada ampla pesquisa na literatura, com especial atenção aos artigos publicados nos últimos três anos e indexados ao PubMed. Foram utilizados os seguintes descritores de forma cruzada: pancreatitis, surgical procedures; necrosis. A pesquisa inicial evidenciou cerca de 13.000 artigos, sendo avaliados os mais relevantes dos últimos três anos além de artigos mais antigos, considerados "clássicos" sobre o assunto e que, portanto, não poderiam deixar de ser citados. CONCLUSÃO: O tratamento da pancreatite aguda envolve um grande número de questões, dentre as quais as mais importantes estão relacionadas ao manejo da antibioticoterapia, tipo de dieta empregada e as questões relacionadas ao manejo da necrose infectada. Em especial, mudanças radicais foram implementadas nos últimos anos sobre todos esses tópicos, e uma atualização constante deve ser obrigatoriamente buscada pelos profissionais envolvidos no tratamento dessa doença.
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Stamatakos M, Stefanaki C, Kontzoglou K, Stergiopoulos S, Giannopoulos G, Safioleas M. Walled-off pancreatic necrosis. World J Gastroenterol 2010; 16:1707-12. [PMID: 20380001 PMCID: PMC2852817 DOI: 10.3748/wjg.v16.i14.1707] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Walled-off pancreatic necrosis (WOPN), formerly known as pancreatic abscess is a late complication of acute pancreatitis. It can be lethal, even though it is rare. This critical review provides an overview of the continually expanding knowledge about WOPN, by review of current data from references identified in Medline and PubMed, to September 2009, using key words, such as WOPN, infected pseudocyst, severe pancreatitis, pancreatic abscess, acute necrotizing pancreatitis (ANP), pancreas, inflammation and alcoholism. WOPN comprises a later and local complication of ANP, occurring more than 4 wk after the initial attack, usually following development of pseudocysts and other pancreatic fluid collections. The mortality rate associated with WOPN is generally less than that of infected pancreatic necrosis. Surgical intervention had been the mainstay of treatment for infected peripancreatic fluid collection and abscesses for decades. Increasingly, percutaneous catheter drainage and endoscopic retrograde cholangiopancreatography have been used, and encouraging results have recently been reported in the medical literature, rendering these techniques invaluable in the treatment of WOPN. Applying the recommended therapeutic strategy, which comprises early treatment with antibiotics combined with restricted surgical intervention, fewer patients with ANP undergo surgery and interventions are ideally performed later in the course of the disease, when necrosis has become well demarcated.
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The value of procalcitonin at predicting the severity of acute pancreatitis and development of infected pancreatic necrosis: systematic review. Surgery 2009; 146:72-81. [PMID: 19541012 DOI: 10.1016/j.surg.2009.02.013] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 02/20/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Many studies have evaluated serum levels of procalcitonin (PCT) as a predictor in the development of severe acute pancreatitis (SAP) and infected pancreatic necrosis (IPN). This study assesses the value of PCT as a marker of development of SAP and IPN. METHODS Medline, Web of Science, the Cochrane clinical trials register, and international conference proceedings were searched systematically for prospective studies, which evaluated the usefulness of PCT as a marker of SAP and IPN. The sensitivity, specificity, and diagnostic odds ratios (DORs) were calculated for each study, and the study quality and heterogeneity among the studies were evaluated. RESULTS Twenty-four of 59 studies identified were included in data extraction. The sensitivity and specificity of PCT for development of SAP were 0.72 and 0.86, respectively (area under the curve [AUC] = 0.87; DOR = 14.9; 95% confidence interval [CI] = 5.6-39.8), albeit with a significant degree of heterogeneity (Q = 28.56, P < .01). The sensitivity and specificity of PCT for prediction of infected pancreatic necrosis were 0.80 and 0.91 (AUC = 0.91; DOR = 28.3; 95% CI = 13.8-58.3) with no significant heterogeneity (Q = 7.83, P = .18). No significant heterogeneity was observed among the studies when only higher quality studies (AUC = 0.91; DOR = 30.7; 95% CI = 10.7-87.8) or studies that used a cutoff PCT level >0.5 ng/mL (AUC = 0.88, 32.8; 95% CI = 10.1-106.6) were included. CONCLUSION Serum measurements of PCT may be valuable in predicting the severity of acute pancreatitis and the risk of developing infected pancreatic necrosis.
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Szentkereszty Z, Sápy P. The role of percutaneous external drainage in the treatment of fluid collections associated with severe acute pancreatitis. What, when and how to drain? Orv Hetil 2007; 148:1395-9. [PMID: 17631476 DOI: 10.1556/oh.2007.27999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A súlyos akut pancreatitist kísérő folyadékgyülem-képződéssel járó lokális szövődmények perkután drenázskezelése, főleg steril esetekben, nem széles körben alkalmazott eljárás. Jelen közlemény célja a perkután drenázs indikációjának, technikájának, korlátjainak és eredményének elemzése az irodalom alapján. A perkután drenázskezelés a súlyos akut pancreatitist kísérő akut folyadékgyülem, az akut pseudocysta és a hasnyálmirigytályog, valamint az elfolyósodott nekrózis kezelésében jelentős szerepet játszik. A fertőzött folyadékgyülemek kezelésére a perkután drenázs mint első kezelés ajánlható. A steril akut folyadékgyülem és pseudocysta kezelésében a drenázskezelés, a sterilitás szabályainak fokozott betartása mellett, a iatrogén fertőzés relatív gyakorisága miatt csak komoly panaszokat okozó esetekben ajánlott. Az elfolyósodott steril és szeptikus nekrózis kezelésében a legjobb eredménnyel a 20–30F vastagságú katéterekkel végzett drenázskezelés, a „sinus tract endoscopy” és a laparoszkóppal asszisztált necrectomia kecsegtet. Az esetek több mint 25%-ában a drenázs a konzervatív kezelés mellett a beteg végleges gyógyulásához vezet. Más esetekben a műtét időpontjának prolongálására, a „korai” műtét elkerülésére hasznos eljárás.
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Affiliation(s)
- Zsolt Szentkereszty
- Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Orvostudományi Kar Sebészeti Intézet, Auguszta Sebészeti Központ Debrecen.
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Abstract
Acute severe pancreatitis remains a disease with multiple complications and high mortality rates. The body of knowledge about clinical pancreatitis is being subjected to rigorous evidence-based analysis, and relevant, practical guidelines have been issued. Great efforts are being made to identify and profile the mediators involved in the systemic hyperinflammatory response to acute pancreatic injury. Lexipafant, a platelet-activating factor antagonist that showed promising results in initial trials, failed to reduce the incidence of new organ failures or mortality in a large double-blind study. The search for an early and accurate prognostic marker for severity persists, with urinary trypsinogen activation peptide as a potentially suitable candidate. Patients with acute pancreatitis do not benefit from anti-secretory therapy with octreotide. Percutaneous, radiological, drainage techniques may eventually play an important role in the management of infected necrosis.
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Affiliation(s)
- A P Wilmer
- Division of Internal Medicine, Medical Intensive Care Unit, Gasthuisberg University Hospital, K.U. Leuven, Leuven, Belgium
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Kaya E, Dervisoglu A, Polat C. Evaluation of diagnostic findings and scoring systems in outcome prediction in acute pancreatitis. World J Gastroenterol 2007; 13:3090-4. [PMID: 17589925 PMCID: PMC4172616 DOI: 10.3748/wjg.v13.i22.3090] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine factors related to disease severity, mortality and morbidity in acute pancreatitis.
METHODS: One hundred and ninety-nine consecutive patients were admitted with the diagnosis of acute pancreatitis (AP) in a 5-year period (1998-2002). In a prospective design, demographic data, etiology, mean hospital admission time, clinical, radiological, biochemical findings, treatment modalities, mortality and morbidity were recorded. Endocrine insufficiency was investigated with oral glucose tolerance test. The relations between these parameters, scoring systems (Ranson, Imrie and APACHE II) and patients’ outcome were determined by using invariable tests and the receiver operating characteristics curve.
RESULTS: One hundred patients were men and 99 were women; the mean age was 55 years. Biliary pancreatitis was the most common form, followed by idiopathic pancreatitis (53% and 26%, respectively). Sixty-three patients had severe pancreatitis and 136 had mild disease. Respiratory rate > 20/min, pulse rate > 90/min, increased C-reactive protein (CRP), lactate dehydrogenase (LDH) and aspartate aminotransferase (AST) levels, organ necrosis > 30% on computed tomography (CT) and leukocytosis were associated with severe disease. The rate of glucose intolerance, morbidity and mortality were 24.1%, 24.8% and 13.6%, respectively. CRP > 142 mg/L, BUN > 22 mg/dL, LDH > 667 U/L, base excess > -5, CT severity index > 3 and APACHE score > 8 were related to morbidity and mortality.
CONCLUSION: APACHE II score, LDH, base excess and CT severity index have prognostic value and CRP is a reliable marker for predicting both mortality and morbidity.
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Affiliation(s)
- Ekrem Kaya
- Ondokuz Mayis University School of Medicine Department of Surgery, Samsun, Turkey.
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Lee JK, Kwak KK, Park JK, Yoon WJ, Lee SH, Ryu JK, Kim YT, Yoon YB. The efficacy of nonsurgical treatment of infected pancreatic necrosis. Pancreas 2007; 34:399-404. [PMID: 17446837 DOI: 10.1097/mpa.0b013e318043c0b1] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES We conducted this study to evaluate the efficacy of nonsurgical treatment for patients with infected pancreatic necrosis (IPN). METHODS Among 224 patients with acute pancreatitis from 2000 to 2004, there were 31 patients diagnosed as having IPN complication. The diagnostic criteria for IPN were either a positive culture or free gas in the pancreas of patients with acute pancreatic necrosis. Nonsurgical management including percutaneous drainage or endoscopic drainage (ED) followed by vigorous irrigation was initially attempted in all patients. Surgery was planned only when there was no clinical improvement after the initial nonsurgical treatment. RESULTS Percutaneous drainage or ED was performed in 18 and 5 patients, respectively. Eight patients received antibiotics only. Four patients (12.9%) (3 from percutaneous drainage group and 1 from ED group) required surgery. Sepsis or fistula developed in 32% and 6% of patients, respectively, and was managed successfully. One patient (3.2%) died as a result of rapidly progressing multiorgan failure. The mean duration of hospitalization was 37 days. During the follow-up period, 7 patients were readmitted because of fever; they were managed by reposition of the drainage tube. CONCLUSIONS Intensive nonsurgical treatment is very effective and safe and should be considered as an initial treatment modality for patients with IPN.
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Affiliation(s)
- Jun Kyu Lee
- Department of Internal Medicine, Dongguk University International Hospital, Dongguk University College of Medicine, Goyang, Korea
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Isenmann R, Henne-Bruns D. Prevention of infectious complications in severe acute pancreatitis with systemic antibiotics: where are we now? Expert Rev Anti Infect Ther 2007; 3:393-401. [PMID: 15954856 DOI: 10.1586/14787210.3.3.393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Infectious complications are the leading cause of death in patients with severe acute pancreatitis. Currently, there is controversy concerning the therapeutic possibilities to reduce the incidence of bacterial infection in this disease. Numerous studies are available which apparently support the prophylactic use of antibiotics in patients with necrotizing pancreatitis. The results, however, are contradicting and interpretation is difficult as these studies have used various antibiotic drugs with different application schemes and heterogeneous study end points. This article gives a critical overview of the background of antibiotic treatment in severe acute pancreatitis, the published data on antibiotic treatment and an outlook on the topics that need to be addressed by future research.
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Affiliation(s)
- Rainer Isenmann
- Department of Abdominal and Transplantation Surgery, University of Ulm, Steinhoevelstrasse 9, 89075 Ulm, Germany.
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20
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Connor S, Raraty MGT, Neoptolemos JP, Layer P, Rünzi M, Steinberg WM, Barkin JS, Bradley EL, Dimagno E. Does infected pancreatic necrosis require immediate or emergency debridement? Pancreas 2006; 33:128-34. [PMID: 16868477 DOI: 10.1097/01.mpa.0000234074.76501.a6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Saxon Connor
- Division of Surgery and Oncology, University of Liverpool, Royal Liverpool University Hospital, Liverpool, United Kingdom
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21
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Pappas TN. Con: Computerized tomographic aspiration of infected pancreatic necrosis: the opinion against its routine use. Am J Gastroenterol 2005; 100:2373-4. [PMID: 16279885 DOI: 10.1111/j.1572-0241.2005.00328_2.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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22
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Maraví Poma E, Jiménez Urra I, Gener Raxarch J, Zubia Olascoaga F, Pérez Mateo M, Casas Curto J, Montejo González J, García de Lorenzo A, López Camps V, Fernández Mondéjar E, Álvarez Lerma F, Vallés Daunis J, Olaechea Astigarraga P, Domínguez Muñoz E, Tellado Rodríguez J, Landa García I, Lafuente Martínez J, Villalba Martín C, Sesma Sánchez J. Recomendaciones de la 7ª Conferencia de Consenso de la SEMICYUC. Pancreatitis aguda grave en Medicina Intensiva. Med Intensiva 2005. [DOI: 10.1016/s0210-5691(05)74245-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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23
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Renzulli P, Jakob SM, Täuber M, Candinas D, Gloor B. Severe acute pancreatitis: case-oriented discussion of interdisciplinary management. Pancreatology 2005; 5:145-56. [PMID: 15849485 DOI: 10.1159/000085266] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The clinical course of an episode of acute pancreatitis varies from a mild, transitory illness to a severe often necrotizing form with distant organ failure and a mortality rate of 20-40%. Patients with severe pancreatitis, representing about 15-20% of all patients with acute pancreatitis, need to be identified as early as possible after onset of symptoms allowing starting intensive care treatment early in the disease process. An episode of severe acute pancreatitis progresses in two phases. The first 10-14 days are characterized by a systemic inflammatory response syndrome maintained by the release of various inflammatory mediators. The second phase, beginning about 10-14 days after the onset of the disease is dominated by sepsis-related morbidity due to infected peripancreatic and pancreatic necrosis. This state is associated with septic multiple organ systemic failure. The importance of infection on the outcome of necrotizing pancreatitis has been clearly delineated and the pre-emptive use of broad-spectrum antibiotics that achieve effective tissue concentrations is considered standard management of patients with severe necrotizing pancreatitis, especially if associated with organ failure or extended necrosis. Patients with infected necrosis should undergo a surgical intervention. The standard open technique consisting of an organ preserving necrosectomy followed by a postoperative concept of lavage and/or drainage to evacuate necrotic debris occurring during the further course has recently been challenged by various minimally invasive approaches.
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Affiliation(s)
- Pietro Renzulli
- Department of Visceral and Transplant Surgery, Inselspital, University of Berne, Berne, Switzerland
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24
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Tzovaras G, Parks RW, Diamond T, Rowlands BJ. Early and long-term results of surgery for severe necrotising pancreatitis. Dig Surg 2003; 21:41-6; discussion 46-7. [PMID: 14707392 DOI: 10.1159/000075825] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2003] [Accepted: 07/25/2003] [Indexed: 01/07/2023]
Abstract
BACKGROUND Necrotising pancreatitis is a challenging problem for the surgeon, as it is associated with considerable morbidity and mortality. The indications, timing of surgical intervention and type of procedure continue to be debated in an effort to improve the outcome of this devastating disease process. METHODS A retrospective analysis of early and long-term results in a series of 44 consecutive patients (34 men, 10 women, median age 46.5, range 13-74 years) who underwent necrosectomy for severe necrotising pancreatitis. In 16 patients necrosectomy and primary abdominal closure with drains was performed, 14 patients had planned staged necrosectomy and delayed abdominal closure with drains, and in 14 patients necrosectomy with open laparostomy was undertaken. RESULTS There were 8 deaths (18%) and 14 cases (32%) of significant hospital morbidity (fistula 10, pseudocyst 2, renal failure 2). Variables which correlated with mortality were: high APACHE II score, acute renal failure requiring dialysis, and requirement for surgical intervention at an early stage (within the first two weeks). A total of 28 late complications occurred in 21 of the surviving patients (endocrine pancreatic insufficiency 10, exocrine pancreatic insufficiency 2, pseudocyst 2, chronic renal failure 2, incisional hernia 10, recurrent pancreatitis 1, and chronic pain 1). CONCLUSIONS Low mortality can be achieved in patients with severe necrotizing pancreatitis with aggressive surgical intervention and careful perioperative management. Long-term morbidity remains high, and emphasises the need for prolonged follow-up.
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Affiliation(s)
- George Tzovaras
- Professorial Surgical Unit, Royal Victoria Hospital, Belfast, Northern Ireland, UK.
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25
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Gloor B, Worni M, Strobel O, Uhl W, Tcholakov O, Müller CA, Stahel PF, Droz S, Büchler MW. Cefepime tissue penetration in experimental acute pancreatitis. Pancreas 2003; 26:117-21. [PMID: 12604907 DOI: 10.1097/00006676-200303000-00005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Antibiotic treatment represents a cornerstone in the management of severe acute pancreatitis. However, different antibiotic substances are currently used. In this study, we analyzed penetration of cefepime into pancreatic tissue in two models of acute pancreatitis. AIMS AND METHODOLOGY Following induction of acute pancreatitis, animals were treated with a single intravenous dose of cefepime (0.1 mg/g of body weight). At two different time points, blood and tissue samples were obtained for determination of cefepime concentration and microbiologic analysis. RESULTS Mean pancreatic tissue concentrations +/- SEM 30 minutes after drug administration were significantly higher in animals with either mild acute pancreatitis (113 +/- 22 mg/kg) or severe acute pancreatitis (75 +/- 22 mg/kg) than in control animals (30 +/- 6 mg/kg) (p < 0.005). The minimal inhibitory concentrations (MIC90) for organisms usually isolated from infected pancreatic necrosis vary between 0.05 and 8 mg/L, which is between nine and 1,500 times lower than the mean peak concentration found in necrotic pancreatic tissue. Seven hours 30 minutes after antibiotic administration, pancreatic cefepime concentrations were still above the MIC90 in 100% and 83% of animals with mild and severe disease, respectively. The infection rate of pancreatic tissue was significantly lower after antibiotic treatment and was similar after imipenem/cilastatin or cefepime treatment. CONCLUSION Because of its antibacterial coverage and proven tissue penetration in acute pancreatitis, cefepime should be studied in patients with severe acute pancreatitis.
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Affiliation(s)
- Beat Gloor
- Department of Visceral and Transplantation Surgery, University of Bern, Switzerland
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26
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Talamonti MS, Denham W. Staging and surgical management of pancreatic and biliary cancer and inflammation. Radiol Clin North Am 2002; 40:1397-410, viii. [PMID: 12479718 DOI: 10.1016/s0033-8389(02)00058-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Management of benign and malignant diseases of the pancreas, liver, and biliary tract has made remarkable progress in the last two decades. Advances in minimally invasive surgery, interventional radiology, and diagnostic and therapeutic endoscopy have changed the treatment of common diseases such as cholelithiasis and more serious diseases such as pancreatic adenocarcinoma. Advances in biliary tract and pancreatic surgery have paralleled the advances in ultrasonographic imaging, CT, and MR imaging. This article outlines the surgeon's perspective on radiologic imaging and preoperative staging of benign and malignant biliary and pancreatic disease.
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Affiliation(s)
- Mark S Talamonti
- Division of Surgical Oncology, Northwestern University, The Feinberg School of Medicine, 201 East Huron, Galter 10-105, Chicago, IL 60611, USA.
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27
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Slavin J, Ghaneh P, Sutton R, Hartley M, Rowlands P, Garvey C, Hughes M, Neoptolemos J. Management of necrotizing pancreatitis. World J Gastroenterol 2001; 7:476-81. [PMID: 11819813 PMCID: PMC4688657 DOI: 10.3748/wjg.v7.i4.476] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Infection complicating pancreatic necrosis leads to persisting sepsis, multiple organ dysfunction syndrome and accounts for about half the deaths that occur following acute pancreatitis. Severe cases due to gallstones require urgent endoscopic sphincterotomy. Patients with pancreatic necrosis should be followed with serial contrast enhanced computed tomography (CE-CT) and if infection is suspected fine needle aspiration of the necrotic area for bacteriology (FNAB) should be undertaken. Treatment of sterile necrosis should initially be non-operative. In the presence of infection necrosectomy is indicated. Although traditionally this has been by open surgery, minimally invasive procedures are a promising new alternative. There are many unresolved issues in the management of pancreatic necrosis. These include, the use of antibiotic prophylaxis, the precise indications for and frequency of repeat CE-CT and FNAB, and the role of enteral feeding.
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Affiliation(s)
- J Slavin
- Senior Lecturer, Department of Surgery, Royal Liverpool University Hospital 5th floor UCD Building, Daulby Street, Liverpool, L69 3GA, United Kingdom, UK.
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28
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Imaging infection in the intensive care unit. Curr Opin Crit Care 1999. [DOI: 10.1097/00075198-199910000-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Abstract
Efforts to unravel the intracellular processes that occur in acute pancreatitis continue. In cerulein pancreatitis, new evidence supports the idea that a very early event is premature trypsinogen activation triggered by lysosomal cathepsin B. Clinicians persist in trying to identify more sensitive and specific prognostic signs of the severity of attacks of pancreatitis; one study suggests that computer-based neural networks may be an alternative to biochemical markers and clinical scoring systems. The systemic severity of episodes of pancreatitis seems to be related to a multitude of proinflammatory cytokines and chemokines acting at sites distant from the pancreas. Selective blockade of some of these peptides (eg, endothelin-1 and platelet-activating factor) has decreased mortality and distant organ damage in animal models and may deserve clinical evaluation. Gene therapy may be more efficient than pharmacologic therapy in increasing anti-inflammatory cytokine (interleukin-10) levels. Clinical studies have further underlined the usefulness of prophylactic antibiotics in severe acute pancreatitis. Radiologic and endoscopic techniques may be alternatives to surgery for certain complications of pancreatitis (eg, infected necrosis and pseudocysts) in particular subsets of patients.
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Affiliation(s)
- H G Hotz
- UCLA School of Medicine, Los Angeles, California 90095, USA
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30
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Abstract
According to epidemiologic studies, the incidence of acute and chronic pancreatitis and carcinoma of the pancreas are increasing worldwide. This is the result not only of improved diagnostic methods introduced in the last decades (eg, contrast-enhanced computed tomography, "all-in-one" magnetic resonance imaging, single-photon emission computed tomography, and endoscopic retrograde cholangiopancreatography) but also of changes in the environment and nutritional behavior. Once a specific diagnosis has been made, the first-choice interventions in acute and chronic inflammatory pancreatic diseases are predominantly organ-and organ function-preserving surgical procedures. In pancreatic cancer, extended radical surgery and multimodal therapies seem to offer the most benefit. This article provides an overview of recently published articles focusing on surgical treatment options in acute and chronic pancreatitis and carcinoma of the pancreas.
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Affiliation(s)
- W Uhl
- Department of Visceral and Transplantation Surgery, University Hospital of Bern, Bern, Switzerland
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