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Kawka M, Lucas A, Riad AM, Hawkins D, de Madaria E, West H, Jakaityte I, Lee MJ, Kouli O, Ruanne R, Gujjuri RR, Brown S, Cambridge WA, Pandanaboyana S, Kamarajah SK, McLean KA. Quality of life instruments in acute and chronic pancreatitis: a consensus-based standards for the selection of health measurement instruments (COSMIN) approach. HPB (Oxford) 2024; 26:859-872. [PMID: 38735815 DOI: 10.1016/j.hpb.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/07/2024] [Accepted: 04/18/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Pancreatitis is a common surgical emergency, associated with pain and poor quality of life for patients. However, assessment of patient-reported outcome measures in these patients is unclear. This study aimed to identify and evaluate the methodological quality of the health-related quality of life instruments used for patients with acute or chronic pancreatitis. METHODS Prospective studies that evaluated health-related quality of life in acute or chronic pancreatitis were identified from systematic review of MEDLINE, EMBASE, and Web of Science until 28th June 2023 (PROSPERO: CRD42021274743). Instrument characteristics were extracted, and methodological quality assessed using COSMIN (COnsensus-based Standards for the selection of health status Measurement Instruments) guidelines and GRADE approach. Narrative synthesis was conducted, with recommendations for use based on COSMIN criteria, evaluated according to World Health Organisation (WHO) quality of life domains. RESULTS From 3850 records screened, 41 quality of life instruments were identified across 138 studies included. The majority (69.8%, n = 26) were designed to assess general health-related quality of life, whereas the remainder were abdominal-specific (n = 5) or pancreas-specific (n = 10). Only ten instruments (24.3%) demonstrated sufficient content validity, incorporating items in ≥5 WHO quality of life domains. However, only nine instruments (21.9%) incorporated public and patient involvement. Only the Gastrointestinal Quality of Life Index and PAN-PROMISE met the criteria to be recommended for use based on COSMIN methodological assessment. CONCLUSION There is significant heterogeneity in instruments used to assess quality of life after pancreatitis, with almost all instruments considered insufficient. Robust, validated, and relevant instruments are needed to better understand and determine appropriate interventions to improve quality of life for these patients.
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Psaltis E, Varghese C, Pandanaboyana S, Nayar M. Quality of life after surgical and endoscopic management of severe acute pancreatitis: A systematic review. World J Gastrointest Endosc 2022; 14:443-454. [PMID: 36051991 PMCID: PMC9329852 DOI: 10.4253/wjge.v14.i7.443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/03/2022] [Accepted: 06/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Treatment for severe acute severe pancreatitis (SAP) can significantly affect Health-related quality of life (HR-QoL). The effects of different treatment strategies such as endoscopic and surgical necrosectomy on HR-QoL in patients with SAP remain poorly investigated.
AIM To critically appraise the available evidence on HR-QoL following surgical or endoscopic necrosectomy in patient with SAP.
METHODS A literature search was performed on PubMed, Google™ Scholar, the Cochrane Library, MEDLINE and Reference Citation Analysis databases for studies that investigated HR-QoL following surgical or endoscopic necrosectomy in patients with SAP. Data collected included patient characteristics, outcomes of interventions and HR-QoL-related details.
RESULTS Eleven studies were found to have evaluated HR-QoL following treatment for severe acute pancreatitis including 756 patients. Three studies were randomized trials, four were prospective cohort studies and four were retrospective cohort studies with prospective follow-up. Four studies compared HR-QoL following surgical and endoscopic necrosectomy. Several metrics of HR-QoL were used including Short Form (SF)-36 and EuroQol. One randomized trial and one cohort study demonstrated significantly improved physical scores at three months in patients who underwent endoscopic necrosectomy compared to surgical necrosectomy. One prospective study that examined HR-QoL following surgical necrosectomy reported some deterioration in the functional status of the patients. On the other hand, a cohort study that assessed the long-term HR-QoL following sequential surgical necrosectomy stated that all patients had SF-36 > 60%. In the only study that examined patients following endoscopic necrosectomy, the HR-QoL was also very good. Three studies investigated the quality adjusted life years suggesting that endoscopic and surgical approaches to management of pancreatic necrosis were comparable in cost effectiveness. Finally, regarding HR-QoL between open necrosectomy and minimally invasive approaches, patients who underwent the later had a significantly better overall quality of life, vitality and mental health.
CONCLUSION This review would suggest that the endoscopic approach might offer better HR-QoL compared to surgical necrosectomy. However, the available comparative literature was very limited. More randomized trials powered to detect differences in HR-QoL are required.
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Affiliation(s)
- Emmanouil Psaltis
- Department of HPB and Transplant Surgery, Newcastle upon Tyne NE7 7DN, United Kingdom
- Department of Surgery, Freeman Hospital, Newcastle upon Tyne NE7 7DN, United Kingdom
| | - Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1010, New Zealand
| | - Sanjay Pandanaboyana
- Department of HPB and Transplant Surgery, Newcastle upon Tyne NE7 7DN, United Kingdom
- Department of Surgery, Freeman Hospital, Newcastle upon Tyne NE7 7DN, United Kingdom
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, United Kingdom
| | - Manu Nayar
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, United Kingdom
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne NE7 7DN, United Kingdom
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Abstract
OBJECTIVES Cost-effectiveness analyses are increasingly used to aid decisions about resource allocation in healthcare; this practice is slow to translate into critical care. We sought to identify and summarize original cost-effectiveness studies presenting cost per quality-adjusted life year, incremental cost-effectiveness ratios, or cost per life-year ratios for treatments used in ICUs. DESIGN We conducted a systematic search of the English-language literature for cost-effectiveness analyses published from 1993 to 2018 in critical care. Study quality was assessed using the Drummond checklist. SETTING Critical care units. PATIENTS OR SUBJECTS Critical care patients. INTERVENTIONS Identified studies with cost-effectiveness analyses. MEASUREMENTS AND MAIN RESULTS We identified 97 studies published through 2018 with 156 cost-effectiveness ratios. Reported incremental cost-effectiveness ratios ranged from -$119,635 (hypothetical cohort of patients requiring either intermittent or continuous renal replacement therapy) to $876,539 (data from an acute renal failure study in which continuous renal replacement therapy was the most expensive therapy). Many studies reported favorable cost-effectiveness profiles (i.e., below $50,000 per life year or quality-adjusted life year). However, several therapies have since been proven harmful. Over 2 decades, relatively few cost-effectiveness studies in critical care have been published (average 4.6 studies per year). There has been a more recent trend toward using hypothetical cohorts and modeling scenarios without proven clinical data (2014-2018: 19/33 [58%]). CONCLUSIONS Despite critical care being a significant healthcare cost burden there remains a paucity of studies in the literature evaluating its cost effectiveness.
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Robin-Lersundi A, Abella Alvarez A, San Miguel Mendez C, Moreno Elalo-Olaso A, Cruz Cidoncha A, Aguilera Velardo A, Gordo Vidal F, García-Ureña MA. Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low-Volume Hospital. World J Surg 2019; 43:2994-3002. [PMID: 31440777 DOI: 10.1007/s00268-019-05114-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Up to 25% of patients with acute pancreatitis develop severe complications and are classified as severe pancreatitis with a high death rate. To improve outcomes, patients may require interventional measures including surgical procedures. Multidisciplinary approach and best practice guidelines are important to decrease mortality. METHODS We have conducted a retrospective analysis from a prospectively maintained database in a low-volume hospital. A total of 1075 patients were attended for acute pancreatitis over a ten-year period. We have analysed 44 patients meeting the criteria for severe acute pancreatitis and for intensive care unit (ICU) admittance. Demographics and clinical data were analysed. Patients were treated according to international guidelines and a multidisciplinary flowchart for acute pancreatitis and a step-up approach for pancreatic necrosis. RESULTS Forty-four patients were admitted to the ICU due to severe acute pancreatitis. Twenty-five patients needed percutaneous drainage of peri-pancreatic or abdominal fluid collections or cholecystitis. Eight patients underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and biliary sepsis or pancreatic leakage, and one patient received endoscopic trans-gastric endoscopic prosthesis for pancreatic necrosis. Sixteen patients underwent surgery: six patients for septic abdomen, four patients for pancreatic necrosis and two patients due to abdominal compartment syndrome. Four patients had a combination of surgical procedures for pancreatic necrosis and for abdominal compartment syndrome. Overall mortality was 9.1%. CONCLUSION Severe acute pancreatitis represents a complex pathology that requires a multidisciplinary approach. Establishing best practice treatments and evidence-based guidelines for severe acute pancreatitis may improve outcomes in low-volume hospitals.
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Affiliation(s)
- Alvaro Robin-Lersundi
- Department of Surgery, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain.
| | - Ana Abella Alvarez
- Department of Intensive Care Medicine, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
| | - Carlos San Miguel Mendez
- Department of Surgery, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
| | - Almudena Moreno Elalo-Olaso
- Department of Surgery, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
| | - Arturo Cruz Cidoncha
- Department of Surgery, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
| | - Asunción Aguilera Velardo
- Department of Surgery, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
| | - Federico Gordo Vidal
- Department of Intensive Care Medicine, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
- Grupo de Investigación en Patología Crítica, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - Miguel-Angel García-Ureña
- Department of Surgery, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
- Grupo de Investigación en Pared Abdominal, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
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Khan S, Ranjha WA, Tariq H, Nawaz H. Efficacy of early oral refeeding in patients of mild acute pancreatitis. Pak J Med Sci 2017; 33:899-902. [PMID: 29067062 PMCID: PMC5648961 DOI: 10.12669/pjms.334.12338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective: To compare Early Oral Refeeding (EORF) with Routine Oral Refeeding (RORF) on outcome of patients of mild Acute Pancreatitis (AP) in terms of Mean Length of Hospital Stay (LOHS). Methods: This randomized controlled trialwas conducted atSurgical Department CMH Rawalpindi, from 1st Feb 2015 to 01st Aug 2016. A total of 60 patients with pain epigastrium were enrolled in the study. Severity of pancreatitis was assessed using Glasgow Scale. Patients were randomly divided in two groups. Group-A was started feeding within 12 hours (EORF group) and Group-B after 12 hours (RORF group). Demographic details and data were recorded on a structured proforma. After discharge, LOHS was measured for both groups and outcome was compared. Results: The groups were comparable with respect to age, sex, etiology, Glasgow Scale, time from onset of pain and Serum Amylase levels at admission. Treatment was standardized according to international guidelines for both groups. The mean LOHS was 7.8 ± 2.14 days in the Group-A and 10.03 ± 1.75 days in Group-B. The difference in the mean LOHS between the two groups was statistically significant (p<0.05). Conclusion: In patients of mild acute pancreatitis, early oral feeding is feasible and safe and has better outcome then those with routine oral refeeding.
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Affiliation(s)
- Shahum Khan
- Dr. Shahum Khan, MBBS, Department of Surgery, CMH Rawalpindi, Pakistan
| | - Waqas Ahmed Ranjha
- Dr. Waqas Ahmed Ranjha, MBBS, Department of Surgery, CMH Rawalpindi, Pakistan
| | - Hassan Tariq
- Dr. Hassan Tariq, MBBS, Armed Forces Institute of Pathology, Rawalpindi, Pakistan
| | - Hareem Nawaz
- Dr. Hareem Nawaz, MBBS, Department of Radiology, CMH Kharian, Pakistan
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Willms A, Schaaf S, Schwab R, Richardsen I, Jänig C, Bieler D, Wagner B, Güsgen C. Intensive care and health outcomes of open abdominal treatment: long-term results of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). Langenbecks Arch Surg 2017; 402:481-492. [PMID: 28382564 DOI: 10.1007/s00423-017-1575-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/08/2017] [Indexed: 01/31/2023]
Abstract
PURPOSE The study's purpose is to evaluate the long-term outcome after vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) and to identify predictors of quality of life associated with intensive care. METHODS Fifty-five patients who underwent open abdomen management at our institution from 2006 to 2013 were prospectively enrolled in this study. After a median follow-up period of 3.8 years, 27 patients completed the 36-Item Short Form Survey (SF-36) quality of life questionnaire. As this is a report solely focused on quality of life, direct treatment-related outcome measures like mortality, closure rates, and incisional hernia development of this study cohort have been reported previously. RESULTS SF-36 physical role (54.6 ± 41.0 (0-100), p < 0.01), physical functioning (68.4 ± 29.5 (0-100), p = 0.01), and physical component summary (41.6 ± 13.0 (19-62), p = 0.01) scores for the patient population were significantly lower than normative scores. Significant correlations were found between physical functioning and total treatment costs (r = -0.66, p = 0.01), total units of packed red blood cells (r = -0.56, p = 0.04), and the complex intensive care scores (r = -0.50, p = 0.02). Simple and multiple regression analyses demonstrated that the complex intensive care score was the only predictor of physical functioning (R 2 = 0.50, β = -0.70, p = 0.02). CONCLUSIONS Despite high short-term mortality and morbidity rates for these critically ill patients, open abdomen treatment using VAWCM allows patients to recover to an acceptable long-term quality of life. The complex intensive care score can be used as a surrogate parameter for the global severity of illness and was the only predictor of physical functioning (SF-36).
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Affiliation(s)
- A Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany.
| | - S Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - R Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - I Richardsen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - C Jänig
- Department of Anesthesiology and Intensive Care, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - D Bieler
- Department of Trauma Surgery and Orthopedics, Plastic and Reconstructive Surgery, and Hand Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - B Wagner
- Support Division of the Directorate-General for Strategy and Operations, Federal Ministry of Defense, Berlin, Germany
| | - C Güsgen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
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da Costa DW, Dijksman LM, Bouwense SA, Schepers NJ, Besselink MG, van Santvoort HC, Boerma D, Gooszen HG, Dijkgraaf MGW. Cost-effectiveness of same-admission versus interval cholecystectomy after mild gallstone pancreatitis in the PONCHO trial. Br J Surg 2016; 103:1695-1703. [DOI: 10.1002/bjs.10222] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 04/18/2016] [Accepted: 05/04/2016] [Indexed: 12/16/2022]
Abstract
Abstract
Background
Same-admission cholecystectomy is indicated after gallstone pancreatitis to reduce the risk of recurrent disease or other gallstone-related complications, but its impact on overall costs is unclear. This study analysed the cost-effectiveness of same-admission versus interval cholecystectomy after mild gallstone pancreatitis.
Methods
In a multicentre RCT (Pancreatitis of biliary Origin: optimal timiNg of CHOlecystectomy; PONCHO) patients with mild gallstone pancreatitis were randomized before discharge to either cholecystectomy within 72 h (same-admission cholecystectomy) or cholecystectomy after 25–30 days (interval cholecystectomy). Healthcare use of all patients was recorded prospectively using clinical report forms. Unit costs of resources used were determined, and patients completed multiple Health and Labour Questionnaires to record pancreatitis-related absence from work. Cost-effectiveness analyses were performed from societal and healthcare perspectives, with the costs per readmission prevented as primary outcome with a time horizon of 6 months.
Results
All 264 trial participants were included in the present analysis, 128 randomized to same-admission cholecystectomy and 136 to interval cholecystectomy. Same-admission cholecystectomy reduced the risk of acute readmission for recurrent gallstone-related complications from 16·9 to 4·7 per cent (P = 0·002). Mean total costs from a societal perspective were €234 (95 per cent c.i. –1249 to 738) less per patient in the same-admission cholecystectomy group. Same-admission cholecystectomy was superior to interval cholecystectomy, with a societal incremental cost-effectiveness ratio of –€1918 to prevent one readmission for gallstone-related complications.
Conclusion
In mild biliary pancreatitis, same-admission cholecystectomy was more effective and less costly than interval cholecystectomy.
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Affiliation(s)
- D W da Costa
- Department of Radiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - L M Dijksman
- Department of Epidemiology and Statistics, Onze Lieve Vrouwe Gasthuis, Academic Medical Centre, Amsterdam, The Netherlands
| | - S A Bouwense
- Department of Operating Theatres and Evidence Based Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - N J Schepers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M G Besselink
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - H C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - D Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - H G Gooszen
- Department of Operating Theatres and Evidence Based Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M G W Dijkgraaf
- Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands
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8
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Abstract
Patient-centered outcomes, including quality of life (QoL), after acute pancreatitis (AP) remain largely unknown. Our aim was to systematically review the best available evidence on QoL after AP. English-language articles on the effect of AP on QoL were identified in MEDLINE, EMBASE, and Scopus. Results were statistically aggregated to obtain a pooled mean difference (MD) and corresponding 95% confidence interval (CI) for individual QoL domains and component summaries, where appropriate. A total of 16 prospective observational studies encompassing 687 AP patients were included. Four studies comprising 267 AP patients, as measured by SF-36 and SF-12 questionnaires, were suitable for meta-analysis. The general health and vitality domains were significantly worse in the patients compared with healthy controls (MD, -10.90; 95% CI, -15.63 to -6.17; P < 0.00001 and MD, -4.64; 95% CI, -7.32 to -1.95; P = 0.0007, respectively). The remaining individual domains and physical and mental component summary scores did not differ between patients and controls. The QoL seems to be significantly impaired in patients after AP with a need to standardize reporting on QoL. Future studies should investigate the effect of different interventions on patients' QoL.
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9
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Zhang H, Ling XL, Wu YY, Lü MH, Guo H, Zhang PB, Zhao XY, Yang SM. CD64 expression is increased in patients with severe acute pancreatitis: clinical significance. Gut Liver 2014; 8:445-51. [PMID: 25071912 PMCID: PMC4113046 DOI: 10.5009/gnl.2014.8.4.445] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 09/23/2013] [Accepted: 09/24/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND/AIMS Upregulated CD64 expression on neutrophils is the most useful marker for acute bacterial infections and systemic inflammation. However, it is unknown whether CD64 is involved in the pathogenesis of acute pancreatitis (AP). This study was designed to determine whether CD64 is implicated in severe acute pancreatitis (SAP), and thus, is a suitable marker for SAP. METHODS SAP was induced in rats with an intraperitoneal injection of L-arginine. CD64 expression in the rat pancreas was determined by quantitative real-time polymerase chain reaction (qRT-PCR) and immunohistochemistry. Additionally, the CD64 mRNA expression in peripheral blood leukocytes from 21 patients with mild acute pancreatitis (MAP) and 10 patients with SAP was investigated at the time of admission and during remission by qRT-PCR. RESULTS CD64 mRNA and protein expression in the pancreas was significantly higher in rats with SAP, compared to the controls. The CD64 expression was higher in the patients with SAP than in the patients with MAP. During remission, CD64 mRNA decreased in both the MAP and SAP patients. The area under the curve of CD64 expression for the detection of SAP was superior to both the Ranson and the Acute Physiology and Chronic Health Evaluation II scores. CONCLUSIONS The CD64 level was significantly increased in correlation with the disease severity in SAP and may act as a useful marker for predicting the development of SAP.
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Affiliation(s)
- Hao Zhang
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing, China ; Department of Gastroenterology, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xian-Long Ling
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Yu-Yun Wu
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Mu-Han Lü
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Hong Guo
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Peng-Bin Zhang
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Xiao-Yan Zhao
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Shi-Ming Yang
- Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing, China ; Biomedical Analysis Center, Third Military Medical University, Chongqing, China ; Chongqing Key Laboratory for Diseases Proteomics, Southwest Hospital, Third Military Medical University, Chongqing, China
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10
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Nutrition, inflammation, and acute pancreatitis. ISRN INFLAMMATION 2013; 2013:341410. [PMID: 24490104 PMCID: PMC3893749 DOI: 10.1155/2013/341410] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 10/30/2013] [Indexed: 12/14/2022]
Abstract
Acute pancreatitis is acute inflammatory disease of the pancreas. Nutrition has a number of anti-inflammatory effects that could affect outcomes of patients with pancreatitis. Further, it is the most promising nonspecific treatment modality in acute pancreatitis to date. This paper summarizes the best available evidence regarding the use of nutrition with a view of optimising clinical management of patients with acute pancreatitis.
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11
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Andersson B, Appelgren B, Sjödin V, Ansari D, Nilsson J, Persson U, Tingstedt B, Andersson R. Acute pancreatitis--costs for healthcare and loss of production. Scand J Gastroenterol 2013; 48:1459-1465. [PMID: 24131379 DOI: 10.3109/00365521.2013.843201] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE. Severity of acute pancreatitis (AP) can vary from a mild to a fulminant disease with high morbidity and mortality. Cost analysis has, however, hitherto been sparse. The aim of this study was to calculate the cost of acute pancreatitis, both including hospital costs and costs due to loss of production. MATERIAL AND METHODS. All adult patients treated at Skane University Hospital, Lund, during 2009-2010, were included. A severity grading was conducted and cost analysis was performed on an individual basis. RESULTS. Two hundred and fifty-two patients with altogether 307 admissions were identified. Mean age was 60 ± 19 years, and 121 patients (48%) were men. Severe AP (SAP) was diagnosed in 38 patients (12%). Thirteen patients (5%) died. Acute biliary pancreatitis was more costly than alcohol induced AP (p < 0.001). Total costs for treating mild AP (MAP) in patients ≤65 years old was lower (p = 0.001) and costs for SAP was higher (p = 0.024), as compared to older patients. The overall hospital cost and cost for loss of production was per person in mean €5,100 ± 2,400 for MAP and €28,200 ± 38,100 for SAP (p < 0.001). The costs for treating AP during the two-year-long study period were in mean €9,762 ± 19,778 per patient. Extrapolated to a national perspective, the annual financial burden for AP in Sweden would be €38,500,000; corresponding to €4,100,000 per million inhabitants. CONCLUSIONS. The costs of treating AP are high, especially in severe cases with a long ICU stay. These results highlight the need to optimize care and continue the identification and focus on SAP, in order to try to limit organ failure and infectious complications.
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Affiliation(s)
- Bodil Andersson
- Departments of Surgery, Clinical science in Lund, Lund University and Skåne University hospital , Lund , Sweden
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Su MS, Jiang Y, Yan XYH, Zhao QH, Liu ZW, Zhang WZ, He L. Alcohol abuse-related severe acute pancreatitis with rhabdomyolysis complications. Exp Ther Med 2012; 5:189-192. [PMID: 23251265 PMCID: PMC3524190 DOI: 10.3892/etm.2012.735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 09/12/2012] [Indexed: 12/13/2022] Open
Abstract
Non-traumatic rhabdomyolysis is a rare complication of acute pancreatitis. One of the major risk factors of both acute pancreatitis and rhabdomyolysis is alcohol abuse. However, only a few studies have reported the prognosis and association of severe acute pancreatitis (SAP) and rhabdomyolysis in alcohol abuse patients. In the present study, we report two cases presenting with SAP complicated by rhabdomyolysis following high-dose alcohol intake. The disease onset, clinical manifestations, laboratory data, diagnosis and treatment procedure of each patient were recorded, and the association with rhabdomyolysis was analyzed. Alcohol consumption was the most predominant cause of SAP and rhabdomyolysis in these patients. SAP-related rhabdomyolysis was primarily induced by the toxicity associated with pancreatic necrosis. The laboratory tests revealed that the concentration of serum creatine kinase (CK) and myoglobin increased and acute renal failure symptoms were present, which provided an exact diagnosis for SAP-induced rhabdomyolysis. Rhabdomyolysis and subsequent hypermyoglobinuria severely impaired kidney function and aggravated hypocalcemia. The therapy of early stage SAP complicated by rhabdomyolysis involved liquid resuscitation support. When first stage treatment fails, blood purification should be performed immediately. Both patients developed multiple organ failure (MOF) and succumbed to the disease. Considering the two cases presented, we conclude that alcohol-related SAP complicated by rhabdomyolysis may have a poor clinical prognosis.
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13
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Quan H, Wang X, Guo C. A meta-analysis of enteral nutrition and total parenteral nutrition in patients with acute pancreatitis. Gastroenterol Res Pract 2011; 2011:698248. [PMID: 21687619 PMCID: PMC3113258 DOI: 10.1155/2011/698248] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Accepted: 03/28/2011] [Indexed: 02/07/2023] Open
Abstract
Objective. To analyze the effect of total parenteral nutrition (TPN) and enteral nutrition (EN) in patients with acute pancreatitis. Methods. Randomized controlled trials of TPN and EN in patients with acute pancreatitis were searched in NCBI and CBM databases and The Cochrane Controlled Trials Register. Six studies were enrolled into the analysis, and the details about the trial designs, characters of the subjects, results of the studies were reviewed by two independent authors and analyzed by STATA 11.0 software. Results. Compared with TPN, EN was associated with a significantly lower incidence of pancreatic infection complications (RR = 0.556, 95% CI 0.436∼0.709, P = .000), MOF (RR = 0.395, 95% CI 0.272∼0.573, P = .003), surgical interventions (RR = 0.556, 95% CI 0.436∼0.709, P = .000), and mortality (RR = 0.426, 95% CI 0.238∼0.764, P = .167). There was no statistic significance in non-pancreatitis-related complications (RR = 0.853, 95% CI 0.490∼1.483, P = .017). However, EN had a significantly higher incidence of non-infection-related complications (RR = 2.697, 95% CI 1.947∼3.735, P = .994). Conclusion. EN could be the preferred nutrition feeding method in patients with acute pancreatitis.
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Affiliation(s)
- Heming Quan
- Department of Gastroenterology, Tenth People's Hospital, Tongji University, Shanghai 200072, China
| | - Xingpeng Wang
- Department of Gastroenterology, Tenth People's Hospital, Tongji University, Shanghai 200072, China
| | - Chuanyong Guo
- Department of Gastroenterology, Tenth People's Hospital, Tongji University, Shanghai 200072, China
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Beenen E, Brown L, Connor S. A comparison of the hospital costs of open vs. minimally invasive surgical management of necrotizing pancreatitis. HPB (Oxford) 2011; 13:178-84. [PMID: 21309935 PMCID: PMC3048969 DOI: 10.1111/j.1477-2574.2010.00267.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Infected necrotizing pancreatitis is a major burden for both the patient and the health care system. Little is known about how hospital costs break down and how they may have shifted with the increasing use of minimally invasive techniques. The aim of this study was to analyse inpatient hospital costs associated with pancreatic necrosectomy. METHODS A prospective database was used to identify all patients who underwent an intervention for necrotizing pancreatitis. Costs of treatment were calculated using detailed information from the Decision Support Department. Costs for open and minimally invasive surgical modalities were compared. RESULTS Twelve open and 13 minimally invasive necrosectomies were performed in a cohort of 577 patients presenting over a 50-month period. One patient in each group died in hospital. Overall median stay was 3.8 days in the intensive care unit (ICU) and 44 days on the ward. The median overall treatment cost was US$ 56,674. The median largest contributors to this total were ward (26.3%), surgical personnel (22.3%) and ICU (17.0%) costs. These did not differ statistically between the two treatment modalities. CONCLUSIONS Pancreatic necrosectomy uses considerable health care resources. Minimally invasive techniques have not been shown to reduce costs. Any intervention that can reduce the length of hospital and, in particular, ICU stay by reducing the incidence of organ failure or by preventing secondary infection is likely to be cost-effective.
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Affiliation(s)
- Edwin Beenen
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
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Andersson B, Pendse ML, Andersson R. Pancreatic function, quality of life and costs at long-term follow-up after acute pancreatitis. World J Gastroenterol 2010; 16:4944-4951. [PMID: 20954281 PMCID: PMC2957603 DOI: 10.3748/wjg.v16.i39.4944] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2010] [Revised: 06/03/2010] [Accepted: 06/10/2010] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate long-term endocrine and exocrine pancreatic function, quality of life and health care costs after mild acute pancreatitis and severe acute pancreatitis (SAP). METHODS Patients prospectively included in 2001-2005 were followed-up after 42 (36-53) mo. Pancreatic function was evaluated with laboratory tests, the oral glucose tolerance test (OGTT), fecal elastase-1 and a questionnaire. Short Form (SF)-36, was completed. RESULTS Fourteen patients with a history of SAP and 26 with mild acute pancreatitis were included. Plasma glucose after OGTT was higher after SAP (9.2 mmol/L vs 7.0 mmol/L, P = 0.044). Diabetes mellitus or impaired glucose tolerance in fasting plasma glucose and/or 120 min plasma glucose were more common in SAP patients (11/14 vs 11/25, P = 0.037). Sick leave, time until the patients could take up recreational activities and time until they had recovered were all longer after SAP (P < 0.001). No significant differences in SF-36 were seen between the groups, or when comparing with age and gender matched reference groups. Total hospital costs, including primary care, follow-up and treatment of complications, were higher after SAP (median €16 572 vs €5000, P < 0.001). CONCLUSION Endocrine pancreatic function was affected, especially after severe disease. SAP requires greater resource use with long recovery, but most patients regained a good quality of life.
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Villatoro E, Mulla M, Larvin M, Cochrane Upper GI and Pancreatic Diseases Group. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev 2010; 2010:CD002941. [PMID: 20464721 PMCID: PMC7138080 DOI: 10.1002/14651858.cd002941.pub3] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pancreatic necrosis may complicate severe acute pancreatitis, and is detectable by computed tomography (CT). If it becomes infected mortality increases, but the use of prophylactic antibiotics raises concerns about antibiotic resistance and fungal infection. OBJECTIVES To determine the efficacy and safety of prophylactic antibiotics in acute pancreatitis complicated by CT proven pancreatic necrosis. SEARCH STRATEGY Searches were updated in November 2008, in The Cochrane Library (Issue 2, 2008), MEDLINE, EMBASE, and CINAHL. Conference proceedings and references from found articles were also searched. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing antibiotics versus placebo in acute pancreatitis with CT proven necrosis. DATA COLLECTION AND ANALYSIS Primary outcomes were mortality and pancreatic infection rates. Secondary end-points included non pancreatic infection, all sites infection, operative rates, fungal infections, and antibiotic resistance. Subgroup analyses were performed for antibiotic regimen (beta-lactam, quinolone, and imipenem). MAIN RESULTS Seven evaluable studies randomised 404 patients. There was no statistically significant effect on reduction of mortality with therapy: 8.4% versus controls 14.4%, and infected pancreatic necrosis rates: 19.7% versus controls 24.4%. Non-pancreatic infection rates and the incidence of overall infections were not significantly reduced with antibiotics: 23.7% versus 36%; 37.5% versus 51.9% respectively. Operative treatment and fungal infections were not significantly different. Insufficient data were provided concerning antibiotic resistance.With beta-lactam antibiotic prophylaxis there was less mortality (9.4% treatment, 15% controls), and less infected pancreatic necrosis (16.8% treatment group, 24.2% controls) but this was not statistically significant. The incidence of non-pancreatic infections was non-significantly different (21% versus 32.5%), as was the incidence of overall infections (34.4% versus 52.8%), and operative treatment rates. No significant differences were seen with quinolone plus imidazole in any of the end points measured. Imipenem on its own showed no difference in the incidence of mortality, but there was a significant reduction in the rate of pancreatic infection (p=0.02; RR 0.34, 95% CI 0.13 to 0.84). AUTHORS' CONCLUSIONS No benefit of antibiotics in preventing infection of pancreatic necrosis or mortality was found, except for when imipenem (a beta-lactam) was considered on its own, where a significantly decrease in pancreatic infection was found. None of the studies included in this review were adequately powered. Further better designed studies are needed if the use of antibiotic prophylaxis is to be recommended.
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Affiliation(s)
- Eduardo Villatoro
- University of NottinghamAcademic Division of Surgery, School of Graduate Entry MedicineDerby City General HospitalUttoxeter RoadDerbyDerbyshireUKDE22 3DT
| | - Mubashir Mulla
- University of NottinghamAcademic Division of Surgery, School of Graduate Entry MedicineDerby City General HospitalUttoxeter RoadDerbyDerbyshireUKDE22 3DT
| | - Mike Larvin
- University of NottinghamAcademic Division of Surgery, School of Graduate Entry MedicineDerby City General HospitalUttoxeter RoadDerbyDerbyshireUKDE22 3DT
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Abstract
OBJECTIVE This study was designed to evaluate the effects of total enteral nutrition and total parenteral nutrition in prevention of pancreatic necrotic infection in severe acute pancreatitis. METHODS One hundred seven patients were enrolled in the study between 2003 and 2007. In the first week of hospitalization, they were randomized to feeding by either total parenteral nutrition (54 patients) or total enteral nutrition (53 patients). All patients were concomitantly administered with sufficient prophylactic antibiotics. Computed tomographic scan and C-reactive protein level indicated a similar clinical severity in both groups. RESULTS Eighty percent of the patients developed organ failure in the group with total parenteral nutrition, which was higher than that in the group with total enteral nutrition (21%). Eighty percent and 22% (P < 0.05) of the patients in the total parenteral nutrition and total enteral nutrition groups, respectively, underwent surgical intervention. The incidence of pancreatic septic necroses in the group with total enteral nutrition (23%) was lower than that in the group with total parenteral nutrition (72%, P < 0.05). Mortality in the total parenteral nutrition group (43%) was higher than in the total enteral nutrition group (11%, P < 0.05). CONCLUSION Total enteral nutrition is better than total parenteral nutrition in the prevention of pancreatic necrotic infection in severe acute pancreatitis.
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Quality of life and functional outcome at 3, 6 and 12 months after acute necrotising pancreatitis. Intensive Care Med 2009; 35:1974-8. [PMID: 19685037 DOI: 10.1007/s00134-009-1616-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Accepted: 06/29/2009] [Indexed: 12/19/2022]
Abstract
PURPOSE To prospectively determine the quality of life and functional outcome at 3, 6 and 12 months following acute necrotising pancreatitis. METHODS Thirty-one consecutive patients with acute necrotising pancreatitis requiring intensive care in our hospital were identified. Survivors were assessed at 3, 6 and 12 months following hospital discharge by an investigator blinded to their previous treatment. Health-related quality of life was assessed by the Short Form 36 (SF-36) questionnaire and functional outcome by the six minute walk test. RESULTS Twenty-one patients (68%) survived to leave hospital. The median score for the physical function domain increased from 32 at 3 months to 38 and 12 months (P = 0.013), but remained lower than the score in the normal population of 88 (P < 0.001). The median physical component summary score increased from 33 at 3 months to 40 at 12 months (P = 0.030), but remained lower than the score in the normal population of 50 (P = 0.009). Between 3 and 12 months the median distance walked in 6-min increased from 358 to 424 m (P = 0.021), but remained lower than the predicted distance of 503 m (P = 0.014). CONCLUSIONS In the first year after acute necrotising pancreatitis patients showed improvement in their physical components of quality of life and in their physical function, but their outcome at 12 months was still poor compared to the general population. This patient group in particular may benefit from a structured rehabilitation programme continuing after hospital discharge.
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Peng YS, Wu CS, Chen YC, Lien JM, Tian YC, Fang JT, Yang C, Chu YY, Hung CF, Yang CW, Chen PC, Tsai MH. Critical illness-related corticosteroid insufficiency in patients with severe acute biliary pancreatitis: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R123. [PMID: 19630953 PMCID: PMC2750175 DOI: 10.1186/cc7978] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Revised: 07/20/2009] [Accepted: 07/24/2009] [Indexed: 01/29/2023]
Abstract
Introduction Gallstones are the most common cause of acute pancreatitis worldwide. Patients with severe acute biliary pancreatitis (SABP) constitute a subgroup of severe acute pancreatitis (SAP) patients in whom systemic inflammation may be triggered and perpetuated by different mechanisms. The aim of this prospective investigation was to examine the adrenal response to corticotropin and the relationship between adrenal function and outcome in patients with SABP. Methods Thirty-two patients with SABP were enrolled in this study. A short corticotropin (250 μg) stimulation test (SST) was performed within the first 24 hours of admission to the ICU. Critical illness related corticosteroid insufficiency (CIRCI) was defined as follows: baseline value less than 10 μg/dL, or cortisol response less than 9 μg/dL. Results CIRCI occurred in 34.4% of patients. The patients with CIRCI were more severely ill as evidenced by higher APACHE II and SOFA scores and numbers of organ system dysfunction on the day of SST. The in-hospital mortality for the entire group was 21.9%. The CIRCI group had a higher hospital mortality rate compared to those with normal adrenal function (45.5% vs. 9.5%, P = 0.032). The hospital survivors had a higher cortisol response to corticotropin (17.4 (8.3–27.1) vs. 7.2 (1.7–12) μg/dL, P = 0.019). The cortisol response to corticotropin inversely correlated with SOFA score and the number of organ dysfunction on the day of SST. The rates of pancreatic necrosis and bacteremia were significantly higher in the CIRCI group (100% vs 42.9%, P = 0.002; 81.8% vs 23.8%, P = 0.003, respectively). Conclusions CIRCI is common in patients with SABP. It is associated with bacteremia, multiple organ dysfunction and increased mortality.
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Affiliation(s)
- Yun-Shing Peng
- Division of Endocrinology, Chang Gung Memorial Hospital, 6, West Section, Chia-Pu Road, Chia-Yi 613, Taiwan.
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Pezzilli R, Morselli-Labate AM, Campana D, Casadei R, Brocchi E, Corinaldesi R. Evaluation of patient-reported outcome in subjects treated medically for acute pancreatitis: a follow-up study. Pancreatology 2009; 9:375-82. [PMID: 19451747 DOI: 10.1159/000181171] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Accepted: 10/29/2008] [Indexed: 12/11/2022]
Abstract
AIMS To explore the quality of life in patients treated medically during the acute phase of pancreatitis as well as at 2 and 12 months after discharge from the hospital. PATIENTS 40 patients were studied. The etiology of the pancreatitis was biliary causes in 31 patients and non-biliary causes in 9; mild disease was present in 29 patients and severe disease in 11. 30 patients completed the two surveys at 2 and 12 months after hospital discharge. METHODS The SF-12 and EORTC QLQ-C30 questionnaires were used for the purpose of the study. RESULTS The two physical and mental component summaries of SF-12, all the domains of EORTC QLQ-C30 (except for physical functioning and cognitive functioning) and some symptom scales of EORTC QLQ-C30 (fatigue, nausea/vomiting, pain, and constipation) were significantly impaired during the acute phase of pancreatitis. There was a significant improvement in the SF-12 physical component summary, and global health, role functioning, social functioning, nausea/vomiting, pain, dyspnea, and financial difficulties (EORTC QLQ-C30) at 2 months after discharge as compared to the basal evaluation. Similar results were found after 12 months except for the mental component score at 12-month evaluation, which was significantly impaired in acute pancreatitis patients in comparison to the norms. The physical functioning of the EORTC QLQ-C30 at basal evaluation was significantly impaired in patients with severe pancreatitis in comparison to patients with mild pancreatitis. CONCLUSIONS Two different patterns can be recognized in the quality of life of patients with acute pancreatitis: physical impairment is immediately present followed by mental impairment which appears progressively in the follow-up period.
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Affiliation(s)
- R Pezzilli
- Department of Digestive Diseases and Internal Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Gonzálvez-Gasch A, de Casasola GG, Martín RB, Herreros B, Guijarro C. A simple prognostic score for risk assessment in patients with acute pancreatitis. Eur J Intern Med 2009; 20:e43-8. [PMID: 19393477 DOI: 10.1016/j.ejim.2008.09.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Revised: 09/06/2008] [Accepted: 09/24/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute pancreatitis (AP) is a common disease that poses potential serious problems. Its clinical course is often unpredictable. Identification of high risk patients enables early appropriate treatment. METHODS We conducted a prospective study to develop a new prognostic method that can objectively and easily grade the severity of AP within the first 72 h of admission. The prediction rule was based on clinical and analytical parameters in 308 patients admitted in a community-based hospital. We validated the score in 193 additional patients in the same hospital. RESULTS Independent prognostic factors related to poor prognosis were age >65 years, leucocytes >13,000/mm(3), albumin <2.5 mg/dL, calcium <8.5 mg/dL and reactive C protein >150 mg/dL. We assigned points to each of the independent factors for complicated AP in proportion to the regression coefficients. We defined three different risk groups according to the points obtained in the prediction rule. Low risk, 0 points (18% patients, 0% risk), moderate, 1-3 points (56% patients, 19% risk) and high, 4-6 points (26% patients, 73% risk). The sensitivity of this formula was 90% with specificity of 63%. The positive and negative predictive values were 50% and 94% respectively. CONCLUSIONS Our simple prediction rule is an additional tool that may help physicians stratifying the severity of AP. Patients with high risk for complicated AP should be kept under close surveillance whereas low risk patients would not need special monitoring.
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Affiliation(s)
- A Gonzálvez-Gasch
- Unidad de Medicina Interna, USP Hospital San Jaime, Partida de la Loma s/n, 03184 Torrevieja, Alicante, Spain.
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Reszetow J, Hać S, Dobrowolski S, Stefaniak T, Wajda Z, Gruca Z, Sledziński Z, Studniarek M. Biliary versus alcohol-related infected pancreatic necrosis: similarities and differences in the follow-up. Pancreas 2007; 35:267-72. [PMID: 17895849 DOI: 10.1097/mpa.0b013e31805b8319] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Infected pancreatic necrosis (IPN) is a serious complication of acute pancreatitis. Data concerning survivors' quality of life and pancreatic functions are scarce. Follow-up of the patients with alcohol and biliary etiology of IPN treated with open necrosectomy was performed. METHODS Twenty-eight survivors after operative treatment (Bradley procedure) of IPN were followed up 24 to 96 months after discharge from the hospital (10 biliary and 18 alcohol patients). Their exocrine and endocrine pancreatic functions and quality of life (Functional Assessment of Chronic Illness Therapy scale) were evaluated. Pancreatic tissue remaining after necrosectomy was visualized by use of contrast-enhanced computed tomography (CT). RESULTS In 44.4% of alcohol-induced IPN patients, the presence of the whole pancreas was shown on the follow-up CT, contrary to the biliary group, where the partial lack of the pancreas was observed in all cases. Pancreatic tissue calcifications were present on CT in 8 patients of alcohol-induced acute pancreatitis group only. Median stool elastase 1 concentrations were 318.1 U/mL in the biliary group and 238.3 U/mL in the alcohol-induced group (not significant). The Functional Assessment of Chronic Illness Therapy scale showed significantly higher social/family and emotional well-being in patients with biliary acute necrotizing pancreatitis. CONCLUSIONS Patients after alcohol-induced IPN had lower quality of life compared with biliary etiology. Biliary and alcohol-induced IPN patients after surgical treatment have nonsignificant differences of endocrine and exocrine pancreatic functions.
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Affiliation(s)
- Jacek Reszetow
- Department of General, Endocrine, and Transplant Surgery, Medical University of Gdańsk, Poland.
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Affiliation(s)
- Stephen J Pandol
- Department of Medicine, Department of Veterans Affairs and University of California, Los Angeles, California, USA.
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Rahman SH, Menon KV, Holmfield JHM, McMahon MJ, Guillou JP. Serum macrophage migration inhibitory factor is an early marker of pancreatic necrosis in acute pancreatitis. Ann Surg 2007; 245:282-9. [PMID: 17245183 PMCID: PMC1877000 DOI: 10.1097/01.sla.0000245471.33987.4b] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine if 24-hour blood concentrations of macrophage migration inhibitory factor (MIF), soluble CD14, and CD163 receptors could predict complications associated with acute pancreatitis (AP). SUMMARY BACKGROUND DATA Soluble receptor proteins derived from the macrophage-monocyte lineage potentiate the inflammatory cytokine response early in AP. Understanding the temporal expression of these molecules could afford better measures for therapeutic intervention. METHODS Patients with AP (amylase >5 times normal) were recruited within 24-hour of onset of pain. Peripheral blood was analyzed for MIF, sCD163, and sCD14 levels and levels correlated with CRP, APACHE-II score, and clinical disease severity (Atlanta criteria); subclassified as multiorgan dysfunction (MOF), pancreatic necrosis (PN >30% on contrast CT), and death. RESULTS In total, 64 patients with AP (severe, 19: 8 had MOF alone, 7 both PN and MOF, 2 PN without MOF, and 2 single-organ failures with local septic complications) were recruited. Both sCD14 and MIF concentrations were elevated in patients with severe attacks (P = 0.004 and P < 0.001 respectively), and patients who developed MOF (P = 0.004 and P < 0.001). However, only serum MIF was significantly raised in patients who subsequently developed PN (median, 92.5 ng/mL; IQR, 26-181 vs. 31.1 ng/mL; IQR, 5-82, P < 0.001), independently of MOF (P = 0.01). Multivariate analysis demonstrated serum MIF as an independent predictor of PN (P = 0.01; OR = 2.73; 95% CI, 2.72-2.74). CONCLUSION The prognostic utility of 24-hour plasma MIF concentration in predicting PN has major clinical and healthcare resource implications. Its mechanistic pathway may afford novel therapeutic interventions in clinical disease by using blocking agents to ameliorate the systemic manifestations of AP.
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Affiliation(s)
- Sakhawat H Rahman
- Division of Surgery, University of Leeds School of Medicine, St. James's University Hospital, UK.
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Reddy M, Jindal R, Gupta R, Yadav TD, Wig JD. Outcome after pancreatic necrosectomy: trends over 12 years at an Indian centre. ANZ J Surg 2007; 76:704-9. [PMID: 16916387 DOI: 10.1111/j.1445-2197.2006.03835.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pancreatic necrosectomy for necrotizing pancreatitis is a formidable operation. There are limited data from the Indian subcontinent regarding outcome and recent trends in management. METHODS Patients undergoing pancreatic necrosectomy over a 12-year period were identified from a prospective database. Data regarding the hospital course, complications and outcome were extracted by case file review. Descriptive statistics were used to present the data. An attempt was made to identify trends in management and outcome over the study period. RESULTS One hundred and eighteen patients underwent necrosectomy. The median age was 39.5 years (interquartile range, 32-46). Median Acute Physiology And Chronic Health Evaluation II score at admission was 8 (interquartile range, 6-10). Thirty-nine patients (33%) had organ failure at admission. Patients underwent surgery a median of 23 days (interquartile range, 14-34) after onset of illness. There was high incidence of loco-regional complications (68/118, 58%) and organ failure (88/118, 75%) in the postoperative period. The mortality rate was 38%. There was an increase in the median onset to surgery interval (17 vs 25.5 days; P = 0.001), increased use of percutaneous interventions (20 vs 36%; P = 0.05) and decreased mortality (47 vs 29%; P = 0.052) in the later half of the study period. CONCLUSION Pancreatic necrosectomy continues to be associated with significant morbidity and mortality in India. A trend towards increased use of percutaneous interventions and delayed surgery is evident.
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Affiliation(s)
- Mettus Reddy
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
Open abdomen is the final result of a variety of diseases and their treatment strategies. The aim of this article is to present systematically late complications after open abdominal therapy and our own treatment results from 2003 to 2005. The main diagnoses for open abdomen are persistent peritonitis, abdominal compartment syndrome, and abdominal injuries. A perioperative mortality rate of 10-56%, long stays at the ICU, and a mean of 3-5 reoperations are characteristic for the severity of such diseases. Late complications may include incisional hernia (47-78%), gastrointestinal and pancreatic fistulas (8-41%), postoperative delayed abscess (10-21%), polyneuropathy (21%), psychic disorders (24%), indigestion (12%), and ossification (17%). These postoperative disorders may range in severity from clinically less significant to therapy-relevant with surgical consequences. Despite the high morbidity, approximately 75% of surviving patients achieve good quality of life. In our opinion, this justifies the extensive treatment concepts and associated high costs.
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Affiliation(s)
- F Eder
- Klinik für Allgemein-, Viszeral- und Gefässchirurgie, Medizinische Fakultät, Otto-von-Guericke-Universität, Leipziger Strasse 44, 39120 , Magdeburg.
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Talmor D, Shapiro N, Greenberg D, Stone PW, Neumann PJ. When is critical care medicine cost-effective? A systematic review of the cost-effectiveness literature. Crit Care Med 2006; 34:2738-47. [PMID: 16957636 DOI: 10.1097/01.ccm.0000241159.18620.ab] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Receiving care in an intensive care unit can greatly influence patients' survival and quality of life. Such treatments can, however, be extremely resource intensive. Therefore, it is increasingly important to understand the costs and consequences associated with interventions aimed at reducing mortality and morbidity of critically ill patients. Cost-effectiveness analyses (CEAs) have become increasingly common to aid decisions about the allocation of scarce healthcare resources. OBJECTIVES To identify published original CEAs presenting cost/quality-adjusted life year or cost/life-year ratios for treatments used in intensive care units, to summarize the results in an accessible format, and to identify areas in critical care medicine that merit further economic evaluation. METHODS We conducted a systematic search of the English-language literature for original CEAs of critical care interventions published from 1993 through 2003. We collected data on the target population, therapy or program, study results, analytic methods employed, and the cost-effectiveness ratios presented. RESULTS We identified 19 CEAs published through 2003 with 48 cost-effectiveness ratios pertaining to treatment of severe sepsis, acute respiratory failure, and general critical care interventions. These ratios ranged from cost saving to 958,423 US dollars/quality-adjusted life year and from 1,150 to 575,054 US dollars/life year gained. Many studies reported favorable cost-effectiveness profiles (i.e., below 50,000 US dollars/life year or quality-adjusted life year). CONCLUSIONS Specific interventions such as activated protein C for patients with severe sepsis have been shown to provide good value for money. However, overall there is a paucity of CEA literature on the management of the critically ill, and further high-quality CEA is needed. In particular, research should focus on costly interventions such as 24-hr intensivist availability, early goal-directed therapy, and renal replacement therapy. Recent guidelines for the conduct of CEAs in critical care may increase the number and improve the quality of future CEAs.
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Affiliation(s)
- Daniel Talmor
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Jamdar S, Siriwardena AK. Contemporary management of infected necrosis complicating severe acute pancreatitis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:101. [PMID: 16356213 PMCID: PMC1550807 DOI: 10.1186/cc3928] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pancreatic necrosis complicating severe acute pancreatitis is a challenging scenario in contemporary critical care practice; it requires multidisciplinary care in a setting where there is a relatively limited evidence base to support decision making. This commentary provides a concise overview of current management of patients with infected necrosis, focusing on detection, the role of pharmacologic intervention, and the timing and nature of surgical interventions. Fine-needle aspiration of necrosis remains the mainstay for establishment of infection. Pharmacological intervention includes antibiotic therapy as an adjunct to surgical debridement/drainage and, more recently, drotrecogin alfa. Specific concerns remain regarding the suitability of drotrecogin alfa in this setting. Early surgical intervention is unhelpful; surgery is indicated when there is strong evidence for infection of necrotic tissue, with the current trend being toward 'less drastic' surgical interventions.
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Affiliation(s)
- Saurabh Jamdar
- Research Fellow, Hepatobiliary Unit, Department of Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Ajith K Siriwardena
- Consultant Surgeon, Hepatobiliary Unit, Department of Surgery, Manchester Royal Infirmary, Manchester, UK
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Cinquepalmi L, Boni L, Dionigi G, Rovera F, Diurni M, Benevento A, Dionigi R. Long-term results and quality of life of patients undergoing sequential surgical treatment for severe acute pancreatitis complicated by infected pancreatic necrosis. Surg Infect (Larchmt) 2006; 7 Suppl 2:S113-6. [PMID: 16895491 DOI: 10.1089/sur.2006.7.s2-113] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Infected pancreatic necrosis (IPN) is one of the most severe complications of acute pancreatitis (AP). Sequential surgical debridement represents one of the most effective treatments in terms of morbidity and mortality. The aim of this paper is to describe the quality of life and long-term results (e.g., nutritional, muscular, and pancreatic function) of patients treated by sequential necrosectomy at the Department of Surgery of the University of Insubria (Varese, Italy). METHODS Data were collected on patients undergoing sequential surgical debridement as treatment for IPN. The severity of AP was evaluated using the Ranson criteria, the Acute Physiology and Chronic Health Evaluation (APACHE II) Score, and the Sepsis Score, as well as the extent of necrosis. The surgical approach was through a midline or subcostal laparotomy, followed by exploration of the peritoneal cavity, wide debridement, and peritoneal lavage. The abdomen was either left open or closed partially with a surgical zipper, with multiple re-laparotomies scheduled until debridement of necrotic tissue was complete. The long-term evaluation focused on late morbidity, performance status, and abdominal wall function. RESULTS In the majority of patients (68%), mixed flora were isolated. Pseudomonas aeruginosa was the microorganism identified most commonly (59%), often associated with Candida albicans or C. glabrata. The mean total hospital stay was 71+/-38 days (range 13-146 days), of which 24+/-19 days (range 0-66 days) were in the intensive care unit. Eight patients died, the deaths being caused by multiple organ dysfunction syndrome in seven patients and hemorrhage from the splenic artery in one. Normal exocrine and endocrine pancreatic function was observed in 28 patients (88%). At discharge, four patients had steatorrhea, which was temporary. Eight patients (23%) developed pancreatic pseudocysts, and in six, cystogastostomy was performed. Most patients (29/32, 91%) developed a post-operative hernia, but only five required surgical repair. All patients had a Short Form (SF)-36 score>60%, and 20 of the 32 patients (68%) had scores>70-80% (good quality of life). The worst scores were related to alcoholic pancreatitis. CONCLUSIONS The degree of pancreatic failure (exocrine and endocrine function) is not related to the amount of pancreatic necrosis. Even with a need for repeated laparotomy and multiple surgical procedures, the abdominal wall capacity as well as long-term quality of life remain excellent.
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McClave SA, Chang WK, Dhaliwal R, Heyland DK. Nutrition support in acute pancreatitis: a systematic review of the literature. JPEN J Parenter Enteral Nutr 2006; 30:143-56. [PMID: 16517959 DOI: 10.1177/0148607106030002143] [Citation(s) in RCA: 206] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Failure to use the gastrointestinal (GI) tract in patients with acute pancreatitis may exacerbate the stress response and disease severity, leading to greater incidence of complications and prolonged hospitalization. The objectives of this study were to determine the optimum route for nutrition support, whether nutrition therapy is better than no artificial nutrition support, whether specific additives to enteral or parenteral therapy can further enhance their efficacy, and whether methodologic differences in delivery of enteral nutrition (EN) influence tolerance. METHODS A computerized search was performed of MEDLINE, Cochrane database, EMBASE, and reference lists of pertinent review articles for prospective randomized trials in adult patients with acute pancreatitis that evaluated interventions with nutrition therapy. Primary outcome data and surrogate endpoint parameters (for nutrition indices, stress markers, and measures of the inflammatory/immune response) were extracted in duplicate independently. Where appropriate, meta-analysis was performed by random-effects model. RESULTS From 119 articles screened, 27 randomized controlled trials were included and analyzed. In patients admitted for acute pancreatitis, meta-analysis of 7 trials showed that use of EN was associated with a significant reduction in infectious morbidity (risk ratio [RR] = 0.46; 95% confidence interval [CI], 0.29 - 0.74; p = .001) and hospital length of stay (LOS; weighted mean difference [WMD] = -3.94; 95% CI, -5.86 to -2.02; p < .0001), a trend toward reduced organ failure (RR = 0.59; 95% CI, 0.28-1.27; p = .18), with no effect on mortality (RR = 0.88; 95% CI, 0.43-1.79; p = .72) when compared with use of parenteral nutrition (PN). Results from individual studies suggest that EN in comparison to PN reduces oxidative stress, hastens resolution of the disease process, and costs less. Insufficient data exist to determine whether EN improves outcome over standard therapy (no artificial nutrition support) in patients admitted for acute pancreatitis. However, in those patients requiring surgery for complications of acute pancreatitis, meta-analysis of 2 trials indicates that provision of EN postoperatively may reduce mortality (RR = 0.26; 95% CI, 0.06 - 1.09; p = .06) compared with standard therapy. PN provided early within 24 hours of admission was shown to worsen outcome, whereas PN provided later after full-volume resuscitation appeared to improve outcome when compared with standard therapy. In early individual studies, specific supplements added to EN, such as arginine, glutamine, omega-3 polyunsaturated fatty acids, and probiotics, may be associated with a positive impact on patient outcome in acute pancreatitis, compared with EN alone without the supplements, but studies are too few to make strong treatment recommendations. Supplementation of PN with parenteral glutamine was shown to reduce oxidative stress and improve patient outcome (reduced duration of nutrition therapy and decreased hospital LOS) compared with PN alone in patients with acute pancreatis. A wide range of tolerance to EN exists, irrespective of known influences such as mode (continuous vs bolus) and level of infusion within the GI tract (gastric vs postpyloric). CONCLUSIONS Patients with acute severe pancreatitis should begin EN early because such therapy modulates the stress response, promotes more rapid resolution of the disease process, and results in better outcome. In this sense, EN is the preferred route and has eclipsed PN as the new "gold standard" of nutrition therapy. When PN is used, it should be initiated after 5 days. The favorable effect of both EN and PN on patient outcome may be further enhanced by supplementation with modulators of inflammation and systemic immunity. Individual variability allows for a wide range of tolerance to EN, even in severe pancreatitis.
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Affiliation(s)
- Stephen A McClave
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY 40202, USA.
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Abstract
Recurrent necrotizing pancreatitis in the frozen or hostile abdomen remains a challenge. Percutaneous drainage is useful in these cases but often fails if there is significant pancreatic necrosis. We describe a technique for laparoscopic drainage of necrotic pancreas. The preexisting percutaneous drainage tract was sequentially dilated and a working thoracoscope was placed via a Hasson cannula. A pulsatile irrigation system was used to open the cavity for visualization and to wash away obvious necrotic debris. Working sequentially using the irrigation jet flow for debridement and visualization, we opened the entire tract and debrided a majority of the necrotic tissue. A large drainage tube was placed to allow the egress of any residual infection. Three patients to date have been treated with the above technique with no intraoperative complications. All three patients did well initially postoperatively and had adequate drainage. One patient developed a delayed pancreatic pseudocyst. Laparoscopic debridement via percutaneous drainage tract is a useful technique in the hostile abdomen.
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Affiliation(s)
- James M. Haan
- From the University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Thomas M. Scalea
- From the University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
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Nathens AB, Curtis JR, Beale RJ, Cook DJ, Moreno RP, Romand JA, Skerrett SJ, Stapleton RD, Ware LB, Waldmann CS. Management of the critically ill patient with severe acute pancreatitis. Crit Care Med 2005; 32:2524-36. [PMID: 15599161 DOI: 10.1097/01.ccm.0000148222.09869.92] [Citation(s) in RCA: 196] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis. The goal of this consensus statement is to provide recommendations regarding the management of the critically ill patient with severe acute pancreatitis (SAP). DATA SOURCES AND METHODS An international consensus conference was held in April 2004 to develop recommendations for the management of the critically ill patient with SAP. Evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature to address specific questions concerning the management of patients with severe acute pancreatitis. DATA SYNTHESIS There were a total of 23 recommendations developed to provide guidance to critical care clinicians caring for the patient with SAP. Topics addressed were as follows. 1) When should the patient admitted with acute pancreatitis be monitored in an ICU or stepdown unit? 2) Should patients with severe acute pancreatitis receive prophylactic antibiotics? 3) What is the optimal mode and timing of nutritional support for the patient with SAP? 4) What are the indications for surgery in acute pancreatitis, what is the optimal timing for intervention, and what are the roles for less invasive approaches including percutaneous drainage and laparoscopy? 5) Under what circumstances should patients with gallstone pancreatitis undergo interventions for clearance of the bile duct? 6) Is there a role for therapy targeting the inflammatory response in the patient with SAP? Some of the recommendations included a recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis. The jury also recommended against pancreatic debridement or drainage for sterile necrosis, limiting debridement or drainage to those with infected pancreatic necrosis and/or abscess confirmed by radiologic evidence of gas or results or fine needle aspirate. Furthermore, the jury recommended that whenever possible, operative necrosectomy and/or drainage be delayed at least 2-3 wk to allow for demarcation of the necrotic pancreas. CONCLUSIONS This consensus statement provides 23 different recommendations concerning the management of patients with SAP. These recommendations differ in several ways from previous recommendations because of the release of recent data concerning the management of these patients and also because of the focus on the critically ill patient. There are a number of important questions that could not be answered using an evidence-based approach, and areas in need of further research were identified.
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Risse O, Auguste T, Delannoy P, Cardin N, Bricault I, Létoublon C. Percutaneous video-assisted necrosectomy for infected pancreatic necrosis. ACTA ACUST UNITED AC 2004; 28:868-71. [PMID: 15523223 DOI: 10.1016/s0399-8320(04)95150-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIMS OF THE STUDY Percutaneous drainage of infected pancreatic necrosis is not always efficient and morbidity is high with open necrosectomy techniques. Minimally-invasive procedures have been developed to reduce this morbidity. We report our early experience with percutaneous video-assisted necrosectomy. METHODS Among 61 patients with acute pancreatitis treated between January 2001 and February 2003, seven developed infected pancreatic necrosis. Six of these seven patients underwent percutaneous video-assisted necrosectomy after failure of radio-guided percutaneous drainage. RESULTS One to four sessions of percutaneous video-assisted necrosectomy were required. There was no death. Sepsis control was achieved in all patients. One patient developed postoperative peritonitis due to intraoperative contamination of the peritoneal cavity. Eighteen months after the last necrosectomy, one patient developed a pseudocyst which was successfully cured by percutaneous drainage. One patient developed diabetes mellitus. CONCLUSION Early experience in six patients has shown that percutaneous video-assisted necrosectomy is feasible, safe and efficient, in accordance with reports in the literature. Further evaluation is necessary.
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Affiliation(s)
- Olivier Risse
- Département de Chirurgie Digestive et de l'Urgence, Hôpital Michallon, BP 217, 38043 Grenoble Cedex 9.
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Flint R, Windsor J, Bonham M. Trends in the management of severe acute pancreatitis: interventions and outcome. ANZ J Surg 2004; 74:335-42. [PMID: 15144253 DOI: 10.1111/j.1445-1433.2004.02940.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Severe acute pancreatitis (SAP) in the intensive care unit (ICU) is a complex and challenging problem. The aim of the present study was to identify trends in management of SAP patients admitted to a tertiary level ICU, and to relate these to changes in interventions and outcome. METHODS Patients admitted to the Department of Critical Care Medicine (DCCM), Auckland Public Hospital with SAP from 1988 to 2001 (inclusive) were identified from the DCCM prospective database, and data were extracted from several sources. RESULTS One hundred and twelve patients (men 69, women 43, mean age (+/-SD) 57.3 years +/- 14.3) were admitted with SAP to DCCM in the 13-year period. Aetiology was gallstones (42%), alcohol (29%), or idiopathic (29%). At admission to DCCM the median duration of symptoms was 7 days (range 1-100) and the mean (+/-SD) Acute Physiology and Chronic Health Evaluation II score was 19.9 +/- 8.2. Ninety-nine patients (88%) had respiratory failure and 79 (71%) had circulatory failure. The number of necrosectomies peaked between 1991 and 1995 (17/35 patients (49%) compared to 4/22 (18%) prior 1991; chi(2) = 6.90, P = 0.032). Abdominal decompression, enteral nutrition, percutaneous tracheostomy, and the use of stents in endoscopic retrograde cholangiopancreatography were introduced over the study period. The length of stay in DCCM did not alter (median 4 days, range 1-60) but there was a reduction in the length of hospital stay (median 36 days to 15 days; anova= 6.16, P = 0.046). The overall mortality was 31% (35/112) and did not alter over the study period. CONCLUSIONS SAP remains a formidable disease with a high mortality despite a number of changes in intensive care and surgical management.
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Affiliation(s)
- Richard Flint
- Hepato-Biliary Pancreatic/Upper Gastrointestinal Unit, Department of General Surgery, Auckland Hospital, Auckland, New Zealand
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Affiliation(s)
- D McNamara
- Department of Gastroenterology, Adelaide and Meath Hospitals, Dublin, Ireland.
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Cinar E, Ateskan U, Baysan A, Mas MR, Comert B, Yasar M, Ozyurt M, Yener N, Mas N, Ozkomur E, Altinatmaz K. Is late antibiotic prophylaxis effective in the prevention of secondary pancreatic infection? Pancreatology 2003; 3:383-388. [PMID: 14526147 DOI: 10.1159/000073653] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2003] [Accepted: 05/30/2003] [Indexed: 02/05/2023]
Abstract
BACKGROUND Secondary infection of the inflamed pancreas is the principal cause of death after severe acute pancreatitis (AP). Although patients are not always managed early in the course of AP in clinical practice, prophylactic antibiotics that were used in experimental studies in rats were always initiated early after induction of pancreatitis. The effectiveness of antibiotics initiated later is unknown. AIM The aim of this study was to compare the effectiveness of ciprofloxacin and meropenem initiated early versus later in the course of acute necrotizing pancreatitis (ANP) in rats. METHODS 100 Sprague-Dawley rats were studied. ANP was induced in rats by intraductal injection of 3% taurocholate. Rats were divided randomly into five groups: group I rats received normal saline as a placebo, group II and IV rats received three times daily meropenem 60 mg/kg i.p. at 2 and 24 h, respectively and group III and V rats received twice daily ciprofloxacin 50 mg/kg i.p. at 2 and 24 h, respectively, after induction. At 96 h, all rats were killed for quantitative bacteriologic study. A point-scoring system of histological features was used to evaluate the severity of pancreatitis. RESULTS Meropenem and ciprofloxacin initiated 2 h after induction of pancreatitis significantly reduced the prevalence of pancreatic infection (p < 0.001 and p < 0.04, respectively) as compared to controls. Neither of the antibiotics initiated later during the course of AP caused a significant decrease in pancreatic infection in rats (p > 0.05). Although the rats treated early infected less frequently than the rats treated later, the comparison reached statistical significance only in the meropenem group (p < 0.02). CONCLUSION Early antibiotic treatment reduces pancreatic infection more efficiently than late antibiotic treatment in ANP in rats.
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Affiliation(s)
- Esref Cinar
- Department of Infectious Diseases, Gulhane School of Medicine, Ankara, Turkey
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Halonen KI, Pettilä V, Leppäniemi AK, Kemppainen EA, Puolakkainen PA, Haapiainen RK. Long-term health-related quality of life in survivors of severe acute pancreatitis. Intensive Care Med 2003; 29:782-6. [PMID: 12684744 DOI: 10.1007/s00134-003-1700-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2002] [Accepted: 01/31/2003] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the health-related quality of life (HRQL) and postdischarge outcome after severe acute pancreatitis. DESIGN AND SETTING Observational study in a department of surgery (surgical and general intensive care unit) in a tertiary care hospital. PATIENTS AND PARTICIPANTS Of 283 patients with severe acute pancreatitis 211 survived; during a follow-up period an additional 27 died. The Rand 36-item Health Survey with accessory question was mailed to 174 eligible patients. The final study population comprised 145 patients (83% response rate). Age- and sex-matched Finnish population scores were compared with the study population; accessory questions were analyzed separately. RESULTS No clinically significant differences were found in long-term HRQL between study patients and the general population. Of the 145 patients 87% returned to work, 27% suffered recurrent pancreatitis, and 43% developed diabetes. Of 113 patients with alcohol-induced severe acute pancreatitis 30% were abstinent and 28% problem drinkers, alcohol-dependent, or alcoholics. CONCLUSIONS Up to 13% of severe acute pancreatitis patients surviving initial hospitalization die within a few years. Among the survivors long-term HRQL is comparable to that of the normal population. The majority return to work and reduce their alcohol consumption markedly.
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Affiliation(s)
- Kimmo I Halonen
- Department of Gastroenterological and General Surgery, Meilahti Hospital, Helsinki University Central Hospital, P.O. Box 340, 00029 Helsinki, Finland.
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Catto JWF, Alexander DJ. Pancreatic debridement in a district general hospital--viable or vulnerable? Ann R Coll Surg Engl 2002; 84:309-13. [PMID: 12398120 PMCID: PMC2504147 DOI: 10.1308/003588402760452394] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Little is known about the outcome after pancreatic debridement in the district general hospital (DGH) setting and the debate about centralisation of pancreatic surgical services continues. We retrospectively reviewed our experience over 2 years, looking particularly at mortality, morbidity and cost. Of 12 cases treated during this period, 8 were women and 7 were gallstone induced. The mean pre-operative age was 56.5 years and pre-operative Apache II score was 15. The rates for postoperative morbidity and mortality were 67% and 25%, respectively In half, digital necrosectomy was performed and in half a regional pancreatic resection. These figures are similar to others found in the literature (comparison with 15 contemporary series). The median cost per patient was 21,487 pounds, mainly due to ITU accommodation (57.4% of total costs). This is similar to other previously published rates and the rate from our local tertiary centre. It is concluded that acceptable results for pancreatic debridement are producible in the DGH at economically viable levels.
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Affiliation(s)
- J W F Catto
- Department of Surgery, York District Hospital, UK.
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Morimoto T, Noguchi Y, Sakai T, Shimbo T, Fukui T. Acute pancreatitis and the role of histamine-2 receptor antagonists: a meta-analysis of randomized controlled trials of cimetidine. Eur J Gastroenterol Hepatol 2002; 14:679-86. [PMID: 12072603 DOI: 10.1097/00042737-200206000-00014] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Acute pancreatitis is a common disorder. Histamine type-2 receptor antagonists (H2RAs) are frequently used in patients with acute pancreatitis to reduce pancreatic juice secretion. However, most of the studies on this topic have involved only a few patients, demonstrating no beneficial effect but without harm. To clarify this matter, a meta-analysis was conducted to assess the efficacy of H2RAs. METHODS All randomized controlled trials written in English comparing the effects of H2RAs with those of placebo were retrieved. Clinical outcome data were extracted and the results pooled to yield odds ratios or weighted mean differences. Two investigators reviewed articles independently and reached a consensus. RESULTS A total of 285 patients from five studies were included. Cimetidine was the only H2RA used to treat acute pancreatitis. The pooled odds ratio of complications for H2RAs versus placebo was 1.64 (95% confidence interval [CI] 0.92 to 2.92). A weighted mean difference of duration of pain was 6.96 h (95% CI -2.50 to 16.43 h) in favour of placebo. CONCLUSIONS Cimetidine is not more effective than placebo in reducing acute pancreatitis-related complications and the duration of pain; rather, the use of cimetidine for acute pancreatitis could be associated with higher rates of complications and pain. Until the results of a large randomized trial show otherwise, H2RAs should not be used in the absence of specific clinical indications.
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Affiliation(s)
- Takeshi Morimoto
- Department of General Medicine and Clinical Epidemiology, Kyoto University Graduate School of Medicine, Japan
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Buter A, Imrie CW, Carter CR, Evans S, McKay CJ. Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis. Br J Surg 2002; 89:298-302. [PMID: 11872053 DOI: 10.1046/j.0007-1323.2001.02025.x] [Citation(s) in RCA: 349] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND All patients with organ dysfunction are currently classified as having severe acute pancreatitis. The aim of this study was to characterize the systemic inflammatory response syndrome (SIRS) and early organ dysfunction in patients with acute pancreatitis and the relationship with overall mortality. METHODS Patients with predicted severe acute pancreatitis of less than 48 h duration had daily organ dysfunction scores and SIRS criteria calculated. These features were then correlated with outcome. RESULTS Of 121 patients, 68 (56 per cent) did not develop organ dysfunction; only two of these patients died (mortality rate 3 per cent). Fifty-three (44 per cent) had early organ dysfunction, of whom 11 died (21 per cent). Organ dysfunction and persistent SIRS were both associated with an increased mortality rate, but on multivariate analysis only deteriorating organ dysfunction was an independent determinant of survival. CONCLUSION Early organ dysfunction in acute pancreatitis usually resolves and in itself has no significant influence on mortality. In contrast, worsening organ dysfunction was associated with death in more than half of the patients (11 of 20); it is this group of patients who should be classified as having severe acute pancreatitis.
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Affiliation(s)
- A Buter
- Lister Department of Surgery, 16 Alexandra Parade, Glasgow Royal Infirmary, Glasgow G31 2ER, UK
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Bosscha K, Reijnders K, Jacobs MH, Post MW, Algra A, van der Werken C. Quality of life after severe bacterial peritonitis and infected necrotizing pancreatitis treated with open management of the abdomen and planned re-operations. Crit Care Med 2001; 29:1539-43. [PMID: 11505122 DOI: 10.1097/00003246-200108000-00007] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine quality of life after severe bacterial peritonitis and infected necrotizing pancreatitis treated with open management of the abdomen and planned re-operations. DESIGN Retrospective chart review. SETTING University hospital intensive care unit, general wards, and outpatient department. PATIENTS Forty-one patients who survived severe bacterial peritonitis and infected necrotizing pancreatitis treated with open management of the abdomen and planned re-operations. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Over a period of 7 yrs, 95 patients underwent open management of the abdomen and planned re-operations for severe bacterial peritonitis and infected necrotizing pancreatitis. Thirty-nine patients died during the initial intensive care unit stay and 12 as a result of nonperitonitis-related systemic diseases after discharge. Four patients were lost or excluded from final analysis. Long-term morbidity and quality of life using Karnofsky and Rankin scores at discharge and at follow-up at least 1 yr after discharge (mean: 4 yrs) and the Sickness Impact Profile (SIP) were determined. The remaining 41 patients reviewed showed significant long-term morbidity, including dysfunction of the abdominal wall resulting from herniation, persistent polyneuropathy, and mental disorders needing psychiatric support. Patients having persistent polyneuropathy and, to a lesser extent, mental disorders, showed significantly lower Karnofsky, higher Rankin, and higher SIP scores. After discharge, performance status of patients improved significantly, as shown by higher Karnofsky and lower Rankin scores, and, because Karnofsky and Rankin scores are closely related to SIP scores, higher SIP scores. Especially in measuring quality of life in terms of social and role management, assessment of the SIP proved to have additional value. CONCLUSIONS About three-quarters of patients who survive open management of the abdomen and planned re-operations for severe bacterial peritonitis and infected necrotizing pancreatitis regain a good quality of life. Some patients, especially those who suffer from persistent polyneuropathy and mental disorders, show restrictions in daily life.
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Affiliation(s)
- K Bosscha
- Department of Surgery, University Hospital Utrecht, Heidelberglaan 100, 3585 CX Utrecht, The Netherlands
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Yu M. Living, not existing, beyond critical care. Crit Care Med 2001; 29:1640-1. [PMID: 11505149 DOI: 10.1097/00003246-200108000-00027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Carter CR, McKay CJ, Imrie CW. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience. Ann Surg 2000; 232:175-80. [PMID: 10903593 PMCID: PMC1421126 DOI: 10.1097/00000658-200008000-00004] [Citation(s) in RCA: 261] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To describe the development of a minimally invasive technique aimed at surgical debridement in addition to simple drainage of the abscess cavity. SUMMARY BACKGROUND DATA Surgical intervention for secondary infection of pancreatic necrosis is associated with a death rate of 25% to 40%. Although percutaneous approaches may drain the abscess, they have often failed in the long term as a result of inability to remove the necrotic material adequately. METHODS Fourteen consecutive patients with infected necrosis secondary to acute pancreatitis were studied. The initial four patients underwent sinus tract endoscopy along a drainage tract for secondary sepsis after prior open necrosectomy. This technique was then modified to allow primary debridement for proven sepsis to be carried out percutaneously in a further 10 patients. The techniques and initial results are described. RESULTS Additional surgery for sepsis was successfully avoided in the initial four patients managed by sinus tract endoscopy, and none died. Of the following 10 patients managed by percutaneous necrosectomy, 2 died. The median inpatient stay was 42 days. There was one conversion for intraoperative bleeding. Eight patients recovered and were discharged from the hospital after a median of three percutaneous explorations. Only 40% of patients required intensive care management after surgery. CONCLUSIONS These initial results in an unselected group of patients are encouraging and show that unlike with percutaneous or endoscopic techniques, both resolution of sepsis and adequate necrosectomy can be achieved. The authors' initial impression of a reduction in postoperative organ dysfunction is particularly interesting; however, the technique requires further evaluation in a larger prospective series.
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Affiliation(s)
- C R Carter
- Department of Upper Gastrointestinal and Pancreatico-Biliary Surgery, Glasgow Royal Infirmary, Glasgow, Scotland.
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Soran A, Chelluri L, Lee KK, Tisherman SA. Outcome and quality of life of patients with acute pancreatitis requiring intensive care. J Surg Res 2000; 91:89-94. [PMID: 10816356 DOI: 10.1006/jsre.2000.5925] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with severe acute pancreatitis often require intensive care unit (ICU) admission, have multiple complications, spend weeks to months in the hospital, and consume a large amount of resources. The aim of this study was to evaluate the ICU course, costs, mortality, and quality of life of patients who require ICU admission for acute pancreatitis. METHODS Patients with acute pancreatitis requiring ICU admission were identified retrospectively. Data regarding in-hospital morbidity, mortality, and hospital costs were obtained. Long-term quality of life was assessed using the Short Form-36 Health Survey (SF-36). RESULTS Fifty-two patients were identified. There were 31 men and 21 women: the mean age was 53 years (range, 22-89). The most common causes of acute pancreatitis were gallstones (44%) and alcoholism (17%). Pulmonary failure (52% required mechanical ventilation) and renal failure (21% required dialysis) were common. There were 39 (75%) hospital survivors and 13 (25%) nonsurvivors. In the first 24 h, the mean Acute Physiology and Chronic Health Evaluation (APACHE) II scores were 10 +/- 6 in survivors and 16 +/- 4 in the nonsurvivors (<0.01). Mean length of ICU (15 +/- 18 and 28 +/- 31 days) and hospital (40 +/- 34 and 38 +/- 34 days) stays were similar in survivors and nonsurvivors, respectively (NS). The mean hospital cost for survivors was $83,611 +/- 88,434 and that for nonsurvivors was $136,730 +/- 95,045 (P = 0. 09). The estimated cost to obtain one hospital survivor was $129,188. Of the 39 hospital survivors, 5 died later, 21 completed the SF-36, and 13 were lost to follow-up. Long-term quality of life (SF-36) was similar to that of an age-matched population. Twenty of twenty-one felt their general health was at least as good as it had been 1 year previously. CONCLUSIONS Patients with severe acute pancreatitis need prolonged ICU and hospital stays. APACHE II may be a good predictor of outcome; further, prospective evaluation is needed. Although resource utilization is high, most patients survive and have good long-term quality of life.
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Affiliation(s)
- A Soran
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Abstract
In acute pancreatitis, pancreatic inflammation may be complicated by the development of pancreatic infection with a high associated mortality. Pancreatic infection is related to the extent of pancreatic inflammation and necrosis and typically occurs in the second or third week of severe disease. It may be associated with a wide range of Gram-positive and Gram-negative bacteria, notably enterobacteria and also with Candida spp. Current surgical practice in the UK is to use prophylactic antimicrobial therapy in patients with severe disease, with the aim of preventing secondary pancreatic infection. Experimental evidence demonstrates that prophylactic antibacterial therapy prevents pancreatic infection and reduces mortality. Furthermore, studies of antibacterial prophylaxis in patients with acute pancreatitis suggest that prophylactic antibacterial therapy is associated with a reduction in mortality, particularly in those with severe disease. In general, broad-spectrum antibiotics have been used in animal and human studies. However, current evidence does not allow comparisons to be made between different antimicrobial agents. Nutritional strategies may also be important in the prevention of pancreatic infection. Enteral, rather than parenteral, nutrition has been associated with an improved clinical outcome in severe pancreatitis.
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Affiliation(s)
- A O Qamruddin
- Department of Microbiology, Salford Royal Hospitals NHS Trust, Hope Hospital, Salford, M6 8HD
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Affiliation(s)
- T H Baron
- Department of Medicine, Mayo Medical School, Rochester, Minn 55905, USA.
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Tsiotos GG, Luque-de León E, Sarr MG. Long-term outcome of necrotizing pancreatitis treated by necrosectomy. Br J Surg 1998; 85:1650-3. [PMID: 9876068 DOI: 10.1046/j.1365-2168.1998.00950.x] [Citation(s) in RCA: 125] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Long-term functional outcome after operative treatment of necrotizing pancreatitis (NP) has not been studied extensively. METHODS Pancreatic function, performance status, recurrence of symptoms and other related problems were analysed in 44 consecutive patients successfully discharged from hospital after operative necrosectomy (1983-1995) and followed up completely for a mean of 5 years. RESULTS Clinical pancreatic insufficiency developed in half the patients. Diabetes mellitus (11 patients), steatorrhoea (six) or both (five) were associated with a mean estimate of 52, 66 and 67 per cent parenchymal necrosis respectively. Normal pancreatic function was associated with 27 per cent parenchymal necrosis (P < 0.05). Diabetes worsened while steatorrhoea tended to improve over time. Abdominal pain and pancreatitis recurred in six and two patients respectively. Performance status worsened in four patients because of recurrent pancreatitis and severe steatorrhoea. Poor long-term performance was associated with a higher Acute Physiology And Chronic Health Evaluation II score on admission (mean 14 versus 9). CONCLUSION NP has prominent effects on long-term pancreatic exocrine and endocrine function in half the patients, but most preserve a good overall functional status. The development of pancreatic insufficiency varies with the extent of pancreatic parenchymal necrosis.
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Affiliation(s)
- G G Tsiotos
- Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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Affiliation(s)
- C D Johnson
- University Surgical Unit, Southampton General Hospital, UK
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