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Hu X, Han Z, Zhou R, Su W, Gong L, Yang Z, Song X, Zhang S, Shu H, Wu D. Altered gut microbiota in the early stage of acute pancreatitis were related to the occurrence of acute respiratory distress syndrome. Front Cell Infect Microbiol 2023; 13:1127369. [PMID: 36949815 PMCID: PMC10025409 DOI: 10.3389/fcimb.2023.1127369] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/20/2023] [Indexed: 03/08/2023] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is the most common cause of organ failure in acute pancreatitis (AP) patients, which associated with high mortality. Specific changes in the gut microbiota have been shown to influence progression of acute pancreatitis. We aimed to determine whether early alterations in the gut microbiota is related to and could predict ARDS occurrence in AP patients. Methods In this study, we performed 16S rRNA sequencing analysis in 65 AP patients and 20 healthy volunteers. The AP patients were further divided into two groups: 26 AP-ARDS patients and 39 AP-nonARDS patients based on ARDS occurrence during hospitalization. Results Our results showed that the AP-ARDS patients exhibited specific changes in gut microbiota composition and function as compared to subjects of AP-nonARDS group. Higher abundances of Proteobacteria phylum, Enterobacteriaceae family, Escherichia-Shigella genus, and Klebsiella pneumoniae, but lower abundances of Bifidobacterium genus were found in AP-ARDS group compared with AP-nonARDS groups. Random forest modelling analysis revealed that the Escherichia-shigella genus was effective to distinguish AP-ARDS from AP-nonARDS, which could predict ARDS occurrence in AP patients. Conclusions Our study revealed that alterations of gut microbiota in AP patients on admission were associated with ARDS occurrence after hospitalization, indicating a potential predictive and pathogenic role of gut microbiota in the development of ARDS in AP patients.
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Affiliation(s)
- Xiaomin Hu
- Department of Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ziying Han
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ruilin Zhou
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wan Su
- Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Liang Gong
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zihan Yang
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao Song
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shuyang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huijun Shu
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Huijun Shu, ; Dong Wu,
| | - Dong Wu
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Huijun Shu, ; Dong Wu,
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Podda M, Pacella D, Pellino G, Coccolini F, Giordano A, Di Saverio S, Pata F, Ielpo B, Virdis F, Damaskos D, De Simone B, Agresta F, Sartelli M, Leppaniemi A, Riboni C, Agnoletti V, Mole D, Kluger Y, Catena F, Pisanu A. coMpliAnce with evideNce-based cliniCal guidelines in the managemenT of acute biliaRy pancreAtitis): The MANCTRA-1 international audit. Pancreatology 2022; 22:902-916. [PMID: 35963665 DOI: 10.1016/j.pan.2022.07.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/24/2022] [Accepted: 07/12/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Reports about the implementation of recommendations from acute pancreatitis guidelines are scant. This study aimed to evaluate, on a patient-data basis, the contemporary practice patterns of management of biliary acute pancreatitis and to compare these practices with the recommendations by the most updated guidelines. METHODS All consecutive patients admitted to any of the 150 participating general surgery (GS), hepatopancreatobiliary surgery (HPB), internal medicine (IM) and gastroenterology (GA) departments with a diagnosis of biliary acute pancreatitis between 01/01/2019 and 31/12/2020 were included in the study. Categorical data were reported as percentages representing the proportion of all study patients or different and well-defined cohorts for each variable. Continuous data were expressed as mean and standard deviation. Differences between the compliance obtained in the four different subgroups were compared using the Mann-Whitney U, Student's t, ANOVA or Kruskal-Wallis tests for continuous data, and the Chi-square test or the Fisher's exact test for categorical data. RESULTS Complete data were available for 5275 patients. The most commonly discordant gaps between daily clinical practice and recommendations included the optimal timing for the index CT scan (6.1%, χ2 6.71, P = 0.081), use of prophylactic antibiotics (44.2%, χ2 221.05, P < 0.00001), early enteral feeding (33.2%, χ2 11.51, P = 0.009), and the implementation of early cholecystectomy strategies (29%, χ2 354.64, P < 0.00001), with wide variability based on the admitting speciality. CONCLUSIONS The results of this study showed an overall poor compliance with evidence-based guidelines in the management of ABP, with wide variability based on the admitting speciality. Study protocol registered in ClinicalTrials.Gov (ID Number NCT04747990).
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Affiliation(s)
- Mauro Podda
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy.
| | - Daniela Pacella
- University of Naples Federico II, Department of Public Health, Naples, Italy
| | - Gianluca Pellino
- 'Luigi Vanvitelli' University of Campania, Naples, Italy; Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Unit, Pisa University Hospital, Pisa, Italy
| | - Alessio Giordano
- Department of General Surgery, Santo Stefano Hospital, Prato, Italy
| | - Salomone Di Saverio
- Department of Surgery, Madonna del Soccorso Hospital, San Benedetto del Tronto, Italy
| | - Francesco Pata
- General Surgery Unit, Nicola Giannettasio Hospital, Corigliano-Rossano, Italy
| | | | - Francesco Virdis
- Trauma and Acute Care Surgery Unit, Niguarda Ca Granda Hospital, Milan, Italy
| | - Dimitrios Damaskos
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
| | - Belinda De Simone
- Department of Emergency and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy/Saint Germain en Laye, Poissy Cedex, France
| | - Ferdinando Agresta
- Department of Surgery, Vittorio Veneto Civil Hospital, Vittorio Veneto, Italy
| | | | - Ari Leppaniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Cristiana Riboni
- Department of Surgery, EOC Regional Hospital, Lugano, Switzerland
| | | | - Damian Mole
- Centre for Inflammation Research, Clinical Surgery, University of Edinburgh, Edinburgh, Scotland, UK
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Adolfo Pisanu
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy
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Jaber S, Garnier M, Asehnoune K, Bounes F, Buscail L, Chevaux JB, Dahyot-Fizelier C, Darrivere L, Jabaudon M, Joannes-Boyau O, Launey Y, Levesque E, Levy P, Montravers P, Muller L, Rimmelé T, Roger C, Savoye-Collet C, Seguin P, Tasu JP, Thibault R, Vanbiervliet G, Weiss E, Jong AD. Pancréatite aiguë grave du patient adulte en soins critiques 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Jaber S, Garnier M, Asehnoune K, Bounes F, Buscail L, Chevaux JB, Dahyot-Fizelier C, Darrivere L, Jabaudon M, Joannes-Boyau O, Launey Y, Levesque E, Levy P, Montravers P, Muller L, Rimmelé T, Roger C, Savoye-Collet C, Seguin P, Tasu JP, Thibault R, Vanbiervliet G, Weiss E, De Jong A. Guidelines for the management of patients with severe acute pancreatitis, 2021. Anaesth Crit Care Pain Med 2022; 41:101060. [PMID: 35636304 DOI: 10.1016/j.accpm.2022.101060] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To provide guidelines for the management of the intensive care patient with severe acute pancreatitis. DESIGN A consensus committee of 22 experts was convened. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS The most recent SFAR and SNFGE guidelines on the management of the patient with severe pancreatitis were published in 2001. The literature now is sufficient for an update. The committee studied 14 questions within 3 fields. Each question was formulated in a PICO (Patients Intervention Comparison Outcome) format and the relevant evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and their application of the GRADE® method resulted in 24 recommendations. Among the formalised recommendations, 8 have high levels of evidence (GRADE 1+/-) and 12 have moderate levels of evidence (GRADE 2+/-). For 4 recommendations, the GRADE method could not be applied, resulting in expert opinions. Four questions did not find any response in the literature. After one round of scoring, strong agreement was reached for all the recommendations. CONCLUSIONS There was strong agreement among experts for 24 recommendations to improve practices for the management of intensive care patients with severe acute pancreatitis.
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Affiliation(s)
- Samir Jaber
- Department of Anaesthesiology and Intensive Care (DAR B), University Hospital Center Saint Eloi Hospital, Montpellier, France; PhyMedExp, Montpellier University, INSERM, CNRS, CHU de Montpellier, Montpellier, France.
| | - Marc Garnier
- Sorbonne Université, GRC 29, DMU DREAM, Service d'Anesthésie-Réanimation et Médecine Périopératoire Rive Droite, Paris, France
| | - Karim Asehnoune
- Service d'Anesthésie, Réanimation chirurgicale, Hôtel Dieu/HME, CHU Nantes, Nantes cedex 1, France; Inserm, UMR 1064 CR2TI, team 6, France
| | - Fanny Bounes
- Toulouse University Hospital, Anaesthesia Critical Care and Perioperative Medicine Department, Toulouse, France; Équipe INSERM Pr Payrastre, I2MC, Université Paul Sabatier Toulouse III, Toulouse, France
| | - Louis Buscail
- Department of Gastroenterology & Pancreatology, University of Toulouse, Rangueil Hospital, Toulouse, France
| | | | - Claire Dahyot-Fizelier
- Anaesthesiology and Intensive Care Department, University hospital of Poitiers, Poitiers, France; INSERM U1070, University of Poitiers, Poitiers, France
| | - Lucie Darrivere
- Department of Anaesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, F-75010, Paris, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; iGReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France
| | - Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation SUD, CHU de Bordeaux, Hôpital Magellan, Bordeaux, France
| | - Yoann Launey
- Critical Care Unit, Department of Anaesthesia, Critical Care and Perioperative Medicine, University Hospital of Rennes, Rennes, France
| | - Eric Levesque
- Department of Anaesthesia and Surgical Intensive Care, AP-HP, Henri Mondor Hospital, Créteil, France; Université Paris-Est Creteil, EnvA, DYNAMiC, Faculté de Santé de Créteil, Creteil, France
| | - Philippe Levy
- Service de Pancréatologie et d'Oncologie Digestive, DMU DIGEST, Université de Paris, Hôpital Beaujon, APHP, Clichy, France
| | - Philippe Montravers
- Université de Paris Cité, INSERM UMR 1152 - PHERE, Paris, France; Département d'Anesthésie-Réanimation, APHP, CHU Bichat-Claude Bernard, DMU PARABOL, APHP, Paris, France
| | - Laurent Muller
- Réanimations et surveillance continue, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes Caremeau, Montpellier, France
| | - Thomas Rimmelé
- Département d'anesthésie-réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France; EA 7426: Pathophysiology of Injury-induced Immunosuppression, Pi3, Hospices Civils de Lyon-Biomérieux-Université Claude Bernard Lyon 1, Lyon, France
| | - Claire Roger
- Réanimations et surveillance continue, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes Caremeau, Montpellier, France; Department of Intensive care medicine, Division of Anaesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Céline Savoye-Collet
- Department of Radiology, Normandie University, UNIROUEN, Quantif-LITIS EA 4108, Rouen University Hospital-Charles Nicolle, Rouen, France
| | - Philippe Seguin
- Service d'Anesthésie Réanimation 1, Réanimation chirurgicale, CHU de Rennes, Rennes, France
| | - Jean-Pierre Tasu
- Service de radiologie diagnostique et interventionnelle, CHU de Poitiers, Poitiers, France; LaTim, UBO and INSERM 1101, University of Brest, Brest, France
| | - Ronan Thibault
- Service Endocrinologie-Diabétologie-Nutrition, CHU Rennes, INRAE, INSERM, Univ Rennes, NuMeCan, Nutrition Metabolisms Cancer, Rennes, France
| | - Geoffroy Vanbiervliet
- Department of Digestive Endoscopy, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France; University of Paris, Paris, France; Inserm UMR_S1149, Centre for Research on Inflammation, Paris, France
| | - Audrey De Jong
- Department of Anaesthesiology and Intensive Care (DAR B), University Hospital Center Saint Eloi Hospital, Montpellier, France; PhyMedExp, Montpellier University, INSERM, CNRS, CHU de Montpellier, Montpellier, France
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Scurt FG, Bose K, Canbay A, Mertens PR, Chatzikyrkou C. [Acute kidney injury following acute pancreatitis (AP-AKI): Definition, Pathophysiology, Diagnosis and Therapy]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:1241-1266. [PMID: 33291178 DOI: 10.1055/a-1255-3413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute pancreatitis (AP) is the most frequent gastrointestinal cause for hospitalization and one of the leading causes of in-hospital deaths. Severe acute pancreatitis is often associated with multiorgan failure and especially with acute kidney injury (AKI). AKI can develop early or late in the course of the disease and is a strong determinator of outcome. The mortality in the case of dialysis-dependent AKI and acute pancreatitis raises exponentially in the affected patients. AP-induced AKI (AP-AKI) shows many similarities but also distinct differences to other causes of AKI occurring in the intensive care unit setting. The knowledge of the exact pathophysiology can help to adjust, control and improve therapeutic approaches to the disease. Unfortunately, there are only a few studies dealing with AP and AKI.In this review, we discuss recent data about pathogenesis, causes and management of AP-AKI in patients with severe acute pancreatitis and exploit in this regard the diagnostic and prognostic potential of respective newer serum and urine markers.
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Affiliation(s)
- Florian Gunnar Scurt
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland.,Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University, Magdeburg, Germany
| | - Katrin Bose
- Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University, Magdeburg, Germany.,Universitätsklinik für Gastroenterologie, Hepatologie und Infektiologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Otto-von-Guericke-Universität, Magdeburg, Deutschland
| | - Ali Canbay
- Ruhr-Universität Bochum, Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Bochum, Deutschland
| | - Peter R Mertens
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland.,Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University, Magdeburg, Germany
| | - Christos Chatzikyrkou
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland.,Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University, Magdeburg, Germany
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Maldonado I, Shetty A, Estay MC, Siña E, Rojas A, Narra V, Varela C. Acute Pancreatitis Imaging in MDCT: State of the Art of Usual and Unusual Local Complications. 2012 Atlanta Classification Revisited. Curr Probl Diagn Radiol 2020; 50:186-199. [PMID: 32553440 DOI: 10.1067/j.cpradiol.2020.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 11/15/2019] [Accepted: 04/06/2020] [Indexed: 01/31/2023]
Abstract
Acute pancreatitis is an inflammatory disease in which most common etiologies are biliary lithiasis and alcoholism. Acute pancreatitis can be classified into 2 groups according to its morphologic features: interstitial edematous pancreatitis and necrotizing acute pancreatitis. The prognosis of this group of diseases and its complications varies significantly and contrast-enhanced computed tomography is the imaging study of choice for the diagnosis and detection of complications. . In this review, we aim to summarize the changes introduced in the revised Atlanta classification and describe other usual and unusual local complications of acute pancreatitis that are not analyzed in that classification. We will also describe early detection signs and provide an accurate interpretation of complications on contrast-enhanced computed tomography that will lead to prompt management decisions which can reduce the morbidity and mortality of these patients.
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Affiliation(s)
- Ignacio Maldonado
- Departamento Imagenología, Clínica Dávila, Facultad de Medicina Universidad de los Andes y Universidad Mayor, Santiago, Chile.
| | - Anup Shetty
- Mallinckdrodt Institute of Radiology (MIR), Washington University in St. Louis, School of Medicine, St. Louis, MO
| | - María Catalina Estay
- Departamento Imagenología, Clínica Dávila, Facultad de Medicina Universidad de los Andes y Universidad Mayor, Santiago, Chile
| | - Eduardo Siña
- Universidad de los Andes, Facultad de Medicina, Santiago, Chile
| | - Alberto Rojas
- Universidad de los Andes, Facultad de Medicina, Santiago, Chile
| | - Vampsi Narra
- Mallinckdrodt Institute of Radiology (MIR), Washington University in St. Louis, School of Medicine, St. Louis, MO
| | - Cristian Varela
- Departamento Imagenología, Clínica Dávila, Facultad de Medicina Universidad de los Andes y Universidad Mayor, Santiago, Chile
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Eckmann C, Isenmann R, Kujath P, Pross A, Rodloff AC, Schmitz FJ. Calculated parenteral initial treatment of bacterial infections: Intra-abdominal infections. GMS INFECTIOUS DISEASES 2020; 8:Doc13. [PMID: 32373438 PMCID: PMC7186812 DOI: 10.3205/id000057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This is the seventh chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter deals with the empirical and targeted antimicrobial therapy of complicated intra-abdominal infections. It includes recommendations for antibacterial and antifungal treatment.
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Affiliation(s)
- Christian Eckmann
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Hannoversch-Münden, Germany
| | - Rainer Isenmann
- Allgemein- und Visceralchirurgie, St. Anna-Virngrund-Klinik Ellwangen, Germany
| | - Peter Kujath
- Chirurgische Klinik, Medizinische Universität Lübeck, Germany
| | - Annette Pross
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Germany
| | - Arne C. Rodloff
- Institut für Medizinische Mikrobiologie und Infektionsepidemiologie, Universitätsklinikum Leipzig, Germany
| | - Franz-Josef Schmitz
- Institut für Laboratoriumsmedizin, Mikrobiologie, Hygiene, Umweltmedizin und Transfusionsmedizin Johannes Wesling Klinikum Minden, Germany
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Ding N, Sun YH, Wen LM, Wang JH, Yang JH, Cheng K, Lin H, Chen QL. Assessment of prophylactic antibiotics administration for acute pancreatitis: a meta-analysis of randomized controlled trials. Chin Med J (Engl) 2020; 133:212-220. [PMID: 31929369 PMCID: PMC7028185 DOI: 10.1097/cm9.0000000000000603] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Recent evidence has shown that prophylactic antibiotic treatment in patients with acute pancreatitis is not associated with a significant decrease in mortality or morbidity. The use and efficacy of prophylactic antibiotic treatment in acute pancreatitis remain controversial. This meta-analysis was conducted to assess whether antibiotic prophylaxis is beneficial in patients with acute pancreatitis. METHODS We searched randomized controlled trials (RCTs) of prophylactic use of antibiotics using Medline (PubMed), Embase, the Cochrane Library, and Web of Science. The data were analyzed using Review Manager 5.3 software. We performed pooled analyses for infected pancreatic necrosis, mortality, surgical intervention, and non-pancreatic infection. Odds ratios (ORs) from each trial were pooled using a random or fixed effects model, depending on the heterogeneity of the included studies. Sub-group analysis or sensitivity analysis was conducted to explore potential sources of heterogeneity, when necessary. RESULTS Totally, 11 RCTs involving 747 participants were included, with an intervention group (prophylactic use of antibiotics, n = 376) and control group (n = 371). No significant differences were found regarding antibiotic prophylaxis with respect to incidence of infected pancreatic necrosis (OR, 0.74; 95% confidence interval [CI], 0.50-1.09; P = 0.13), surgical intervention (OR, 0.92; 95% CI, 0.62-1.38; P = 0.70), and morality (OR, 0.71; 95% CI, 0.44-1.15; P = 0.16). However, antibiotic prophylaxis was associated with a statistically significant reduction in the incidence of non-pancreatic infection (OR, 0.59; 95% CI, 0.42-0.84; P = 0.004). CONCLUSIONS Prophylactic antibiotics can reduce the incidence of non-pancreatic infection in patients with AP.
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Affiliation(s)
- Nan Ding
- Department of Pharmacy, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830054, China
| | - Yong-Hui Sun
- Digestion and Vascular Center, Department of Pancreas Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830054, China
| | - Li-Mei Wen
- Department of Pharmacy, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830054, China
| | - Jian-Hua Wang
- Department of Pharmacy, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830054, China
| | - Jian-Hua Yang
- Department of Pharmacy, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830054, China
| | - Kun Cheng
- Digestion and Vascular Center, Department of Pancreas Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830054, China
| | - Hai Lin
- Digestion and Vascular Center, Department of Pancreas Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830054, China
| | - Qi-Long Chen
- Digestion and Vascular Center, Department of Pancreas Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830054, China
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9
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Montravers P, Kantor E, Constantin JM, Lefrant JY, Lescot T, Nesseler N, Paugam C, Jabaudon M, Dupont H. Epidemiology and prognosis of anti-infective therapy in the ICU setting during acute pancreatitis: a cohort study. Crit Care 2019; 23:393. [PMID: 31805988 PMCID: PMC6896276 DOI: 10.1186/s13054-019-2681-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 11/21/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recent international guidelines for acute pancreatitis (AP) recommend limiting anti-infective therapy (AIT) to cases of suspected necrotizing AP or nosocomial extrapancreatic infection. Limited data are available concerning empirical and documented AIT prescribing practices in patients admitted to the intensive care unit (ICU) for the management of AP. METHODS Using a multicentre, retrospective (2009-2014), observational database of ICU patients admitted for AP, our primary objective was to assess the incidence of AIT prescribing practices during the first 30 days following admission. Secondary objectives were to assess the independent impact of centre characteristics on the incidence of AIT and to identify factors associated with crude hospital mortality in a logistic regression model. RESULTS In this cohort of 860 patients, 359 (42%) received AIT on admission. Before day 30, 340/359 (95%) AIT patients and 226/501 (45%) AIT-free patients on admission received additional AIT, mainly for intra-abdominal and lung infections. A large heterogeneity was observed between centres in terms of the incidence of infections, therapeutic management including AIT and prognosis. Administration of AIT on admission or until day 30 was not associated with an increased mortality rate. Patients receiving AIT on admission had increased rates of complications (septic shock, intra-abdominal and pulmonary infections), therapeutic (surgical, percutaneous, endoscopic) interventions and increased length of ICU stay compared to AIT-free patients. Patients receiving delayed AIT after admission and until day 30 had increased rates of complications (respiratory distress syndrome, intra-abdominal and pulmonary infections), therapeutic interventions and increased length of ICU stay compared to those receiving AIT on admission. Risk factors for hospital mortality assessed on admission were age (adjusted odds ratio [95% confidence interval] 1.03 [1.02-1.05]; p < 0.0001), Balthazar score E (2.26 [1.43-3.56]; p < 0.0001), oliguria/anuria (2.18 [1.82-4.33]; p < 0.0001), vasoactive support (2.83 [1.73-4.62]; p < 0.0001) and mechanical ventilation (1.90 [1.15-3.14]; p = 0.011), but not AIT (0.63 [0.40-1.01]; p = 0.057). CONCLUSIONS High proportions of ICU patients admitted for AP receive AIT, both on admission and during their ICU stay. A large heterogeneity was observed between centres in terms of incidence of infections, AIT prescribing practices, therapeutic management and outcome. AIT reflects the initial severity and complications of AP, but is not a risk factor for death.
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Affiliation(s)
- Philippe Montravers
- Département d'Anesthésie-Réanimation, CHU Bichat-Claude Bernard, HUPNVS, APHP, 48 rue Henri Huchard, F-75018, Paris, France.
- Université de Paris, Paris, France.
- INSERM UMR 1152 - Université de Paris, Paris, France.
| | - Elie Kantor
- Département d'Anesthésie-Réanimation, CHU Bichat-Claude Bernard, HUPNVS, APHP, 48 rue Henri Huchard, F-75018, Paris, France
- Université de Paris, Paris, France
| | - Jean-Michel Constantin
- Département de Médecine Post-opératoire, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Jean-Yves Lefrant
- Division of Anaesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, and EA 2992, Université Montpellier, Nîmes, France
| | - Thomas Lescot
- Department of Anaesthesia and Critical Care, Saint-Antoine University Hospital, Assistance Publique-Hôpitaux de Paris, and Sorbonne Universités, UPMC Univ Paris 06, Paris, France
| | - Nicolas Nesseler
- Surgical Intensive Care Unit, Hôpital Pontchaillou, and Inserm U 991, Université de Rennes 1, Rennes, France
| | - Catherine Paugam
- Université de Paris, Paris, France
- Department of Anaesthesiology and Critical Care Medicine, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Matthieu Jabaudon
- Département de Médecine Post-opératoire, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Hervé Dupont
- Medical and Surgical ICU, Amiens University Hospital and INSERM U1088, University of Picardy Jules Verne, Amiens, France
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10
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Abstract
The risks, measurements of severity, and management of severe acute pancreatitis and its complications have evolved rapidly over the past decade. Evidence suggests that initial goal directed therapy, nutritional support, and vigilance for pancreatic complications are best practice. Patients can develop pancreatic fluid collections including acute pancreatic fluid collections, pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis. Several randomized controlled trials and cohort studies have recently highlighted the advantage of managing these conditions with a progressive approach, with initial draining for infection followed by less invasive techniques. Surgery is no longer an early intervention and may not be needed. Instead, interventional radiologic and endoscopic methods seem to be safer with at least as good survival outcomes. Newly developed evidence based quality indicators are available to assess and improve performance. Development and clinical testing of drugs to target the mechanisms of disease are necessary for further advancements.
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Affiliation(s)
- O Joe Hines
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-6904, USA
| | - Stephen J Pandol
- Department of Medicine, Cedar-Sinai Medical Center, Los Angeles, CA 90048, USA
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11
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Choi K, Flynn DE, Karunairajah A, Hughes A, Bhasin A, Devereaux B, Chandrasegaram MD. Management of infected pancreatic necrosis in the setting of concomitant rectal cancer: A case report and review of literature. World J Gastrointest Surg 2019; 11:237-246. [PMID: 31123561 PMCID: PMC6513786 DOI: 10.4240/wjgs.v11.i4.237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 03/26/2019] [Accepted: 04/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatitis with infected necrosis is a severe complication of acute pancreatitis and carries with it high rates of morbidity and mortality. The management of infected pancreatic necrosis alongside concomitant colorectal cancer has never been described in literature.
CASE SUMMARY A 77 years old gentleman presented to the Emergency Department of our hospital complaining of ongoing abdominal pain for 8 h. The patient had clinical features of pancreatitis with a raised lipase of 3810 U/L, A computed tomography (CT) abdomen confirmed pancreatitis with extensive peri-pancreatic edema. During the course of his admission, the patient had persistent high fevers and delirium thought secondary to infected necrosis, prompting the commencement of broad-spectrum antibiotic therapy with Piperacillin/Tazobactam. Subsequent CT abdomen confirmed extensive pancreatic necrosis (over 70%). Patient was managed with supportive therapy, nutritional support and gut rest initially and improved over the course of his admission and was discharged 42 d post admission. He represented 24 d following his discharge with fever and chills and a repeat CT abdomen scan noted gas bubbles within the necrotic pancreatic tissue thereby confirming infected necrotic pancreatitis. This CT scan also revealed asymmetric thickening of the rectal wall suspicious for malignancy. A rectal cancer was confirmed on flexible sigmoidoscopy. The patient underwent two endoscopic necrosectomies and was treated with intravenous antibiotics and was discharged after 28 d. Within 1 wk post discharge, the patient commenced a course of neoadjuvant radiotherapy and subsequently underwent concomitant chemotherapy prior to undergoing a successful Hartmann’s procedure for treatment of his colorectal cancer.
CONCLUSION This case highlights the efficacy of endoscopic necrosectomy, early enteral feeding and targeted antibiotic therapy for timely management of infected necrotic pancreatitis. The prompt resolution of pancreatitis permitted the patient to undergo neoadjuvant treatment and resection for his concomitant colorectal cancer.
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Affiliation(s)
- Kihoon Choi
- Department of Surgery, Gold Coast University Hospital, Southport, QLD 4215, Australia
| | - David E Flynn
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Anitha Karunairajah
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Andrew Hughes
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Ambika Bhasin
- Department of Radiology, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Benedict Devereaux
- Department of Gastroenterology, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
| | - Manju D Chandrasegaram
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
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12
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Barrie J, Jamdar S, Smith N, McPherson SJ, Siriwardena AK, O'Reilly DA. Mis-use of antibiotics in acute pancreatitis: Insights from the United Kingdom's National Confidential Enquiry into patient outcome and death (NCEPOD) survey of acute pancreatitis. Pancreatology 2018; 18:721-726. [PMID: 30075909 DOI: 10.1016/j.pan.2018.05.485] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/21/2018] [Accepted: 05/22/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND International guidelines for the management of acute pancreatitis state that antibiotics should only be used to treat infectious complications. Antibiotic prophylaxis is not recommended. The aim of this study was to analyse antibiotic use, and its appropriateness, from a national review of acute pancreatitis. METHODS Data were collected from The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) study into the management of acute pancreatitis. Adult patients admitted to hospitals in England and Wales between January and June 2014 with a coded diagnosis of acute pancreatitis were included. Clinical and organisational questionnaires were used to collect data and these submissions subjected to peer review. Antibiotic use, including indication and duration were analysed. RESULTS 439/712 (62%) patients received antibiotics, with 891 separate prescriptions and 23 clinical indications. A maximum of three courses of antibiotics were prescribed, with 41% (290/712) of patients receiving a second course and 24% (174/712) a third course. For the first antibiotic prescription, the most common indication was "unspecified" (85/439). The most common indication for the second course was sepsis (54/290), "unspecified" was the most common indication for the third course (50/174). In 72/374 (19.38%) the indication was deemed inappropriate by the clinicians and in 72/393 (18.3%) by case reviewers. CONCLUSIONS Inappropriate use of antibiotics in acute pancreatitis is common. Healthcare providers should ensure that antimicrobial policies are in place as part of an antimicrobial stewardship process. This should include specific guidance on their use and these policies must be accessible, adherence audited and frequently reviewed.
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Affiliation(s)
- Jenifer Barrie
- Regional Hepato-pancreato-biliary Unit, Manchester Royal Infirmary, Manchester, UK
| | - Saurabh Jamdar
- Regional Hepato-pancreato-biliary Unit, Manchester Royal Infirmary, Manchester, UK
| | - Neil Smith
- National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK
| | - Simon J McPherson
- National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK
| | - Ajith K Siriwardena
- Regional Hepato-pancreato-biliary Unit, Manchester Royal Infirmary, Manchester, UK; Faculty of Medicine, University of Manchester, Manchester, UK
| | - Derek A O'Reilly
- Regional Hepato-pancreato-biliary Unit, Manchester Royal Infirmary, Manchester, UK; Faculty of Medicine, University of Manchester, Manchester, UK. derek.o'
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13
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Nakaharai K, Morita K, Jo T, Matsui H, Fushimi K, Yasunaga H. Early prophylactic antibiotics for severe acute pancreatitis: A population-based cohort study using a nationwide database in Japan. J Infect Chemother 2018; 24:753-758. [DOI: 10.1016/j.jiac.2018.05.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 04/26/2018] [Accepted: 05/26/2018] [Indexed: 12/22/2022]
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14
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Tian X, Pi YP, Liu XL, Chen H, Chen WQ. Supplemented Use of Pre-, Pro-, and Synbiotics in Severe Acute Pancreatitis: An Updated Systematic Review and Meta-Analysis of 13 Randomized Controlled Trials. Front Pharmacol 2018; 9:690. [PMID: 30002627 PMCID: PMC6031870 DOI: 10.3389/fphar.2018.00690] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 06/07/2018] [Indexed: 01/30/2023] Open
Abstract
Introduction: The role of pre-, pro-, and synbiotics supplemented to standard enteral nutrition in severe acute pancreatitis (SAP) remains unclear. We performed this updated meta-analysis to determine the value of pre-, pro- and synbiotics supplemented to standard enteral nutrition in predicted SAP. Methods: A systematic search in PubMed, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases was performed. Eligible studies were randomized controlled trials (RCTs) that compared the effects of pre-, pro-, and synbiotics supplemented to standard enteral nutrition with control regime in predicted SAP patients. Risk ratio (RR) and mean difference (MD) with 95% confidence interval (95% CI) were used to express the estimates of dichotomous and continuous data respectively. Results: 13 RCTs comprising an aggregate total of 950 patients were eventually enrolled. Pooled results suggested that supplemented use of pre-, pro- and synbiotics effectively shorten the length of hospital stay in Chinese SAP cohorts (6 RCTs, MD = −5.57, 95% CI = −8.21 to −2.93, P < 0.001); however significant differences with regard to remaining clinical outcomes were not detected for all patients. Further analysis based on category of interventions including pre-, pro- and synbiotics also confirmed the findings to be reliable. Conclusions: Supplemented use of pre-, pro and synbiotics reduced the length of hospital stay in Chinese SAP cohorts. And thus, we concluded that pre-, pro- and synbiotics supplemented to standard enteral nutrition may be a potential option for the treatment of SAP patients. However, we also suggest designing further studies with large-scale and rigorous methods of addressing data to establish the effects and safety of supplemented use of pre-, pro- and synbiotics for SAP patients due to the presence of limitations.
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Affiliation(s)
- Xu Tian
- Department of Gastroenterology, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital & Chongqing Cancer Hospital & Chongqing Cancer Institute, Chongqing, China.,Editorial Office, TMR Integrative Nursing, TMR Publishing Group, Tianjin, China
| | - Yuan-Ping Pi
- Department of Nursing, Key Laboratory for Biorheological Science and Technology of Ministry of Education (Chongqing University), Chongqing University Cancer Hospital & Chongqing Cancer Hospital & Chongqing Cancer Institute, Chongqing, China
| | - Xiao-Ling Liu
- Department of Gastroenterology, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital & Chongqing Cancer Hospital & Chongqing Cancer Institute, Chongqing, China
| | - Hui Chen
- Department of Gastroenterology, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital & Chongqing Cancer Hospital & Chongqing Cancer Institute, Chongqing, China
| | - Wei-Qing Chen
- Department of Gastroenterology, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital & Chongqing Cancer Hospital & Chongqing Cancer Institute, Chongqing, China
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15
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Shah AP, Mourad MM, Bramhall SR. Acute pancreatitis: current perspectives on diagnosis and management. J Inflamm Res 2018; 11:77-85. [PMID: 29563826 PMCID: PMC5849938 DOI: 10.2147/jir.s135751] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The last two decades have seen the emergence of significant evidence that has altered certain aspects of the management of acute pancreatitis. While most cases of acute pancreatitis are mild, the challenge remains in managing the severe cases and the complications associated with acute pancreatitis. Gallstones are still the most common cause with epidemiological trends indicating a rising incidence. The surgical management of acute gallstone pancreatitis has evolved. In this article, we revisit and review the methods in diagnosing acute pancreatitis. We present the evidence for the supportive management of the condition, and then discuss the management of acute gallstone pancreatitis. Based on the evidence, our local institutional pathways, and clinical experience, we have produced an outline to guide clinicians in the management of acute gallstone pancreatitis.
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Affiliation(s)
- Adarsh P Shah
- Department of Surgery, Hereford County Hospital, Hereford, UK
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16
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Mazuski JE, Tessier JM, May AK, Sawyer RG, Nadler EP, Rosengart MR, Chang PK, O'Neill PJ, Mollen KP, Huston JM, Diaz JJ, Prince JM. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt) 2017; 18:1-76. [PMID: 28085573 DOI: 10.1089/sur.2016.261] [Citation(s) in RCA: 358] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.
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Affiliation(s)
- John E Mazuski
- 1 Department of Surgery, Washington University School of Medicine , Saint Louis, Missouri
| | | | - Addison K May
- 3 Department of Surgery, Vanderbilt University , Nashville, Tennessee
| | - Robert G Sawyer
- 4 Department of Surgery, University of Virginia , Charlottesville, Virginia
| | - Evan P Nadler
- 5 Division of Pediatric Surgery, Children's National Medical Center , Washington, DC
| | - Matthew R Rosengart
- 6 Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Phillip K Chang
- 7 Department of Surgery, University of Kentucky , Lexington, Kentucky
| | | | - Kevin P Mollen
- 9 Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jared M Huston
- 10 Department of Surgery, Hofstra Northwell School of Medicine , Hempstead, New York
| | - Jose J Diaz
- 11 Department of Surgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Jose M Prince
- 12 Departments of Surgery and Pediatrics, Hofstra-Northwell School of Medicine , Hempstead, New York
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17
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Abstract
BACKGROUND Severe acute pancreatitis is a subtype of acute pancreatitis, associated with multiple organ failure and systemic inflammatory response syndrome. In this qualitative review we looked at the principles of pathogenesis, classification and surgical management of severe acute pancreatitis. We also looked at the current shift in paradigm in the management of severe acute pancreatitis since the guideline developed by the British Society of Gastroenterology. DATA SOURCES Studies published between 1st January 1991 and 31st December 2015 were identified with PubMed, MEDLINE, EMBASE and Google Scholar online search engines using the following Medical Subject Headings: "acute pancreatitis, necrosis, mortality, pathogenesis, incidence" and the terms "open necrosectomy and minimally invasive necrosectomy". The National Institute of Clinical Excellence (NICE) Guidelines were also included in our study. Inclusion criteria for our clinical review included established guidelines, randomized controlled trials and non-randomized controlled trials with a follow-up duration of more than 6 weeks. RESULTS The incidence of severe acute pancreatitis within the UK is significantly rising and pathogenetic theories are still controversial. In developed countries, the most common cause is biliary calculi. The British Society of Gastroenterology, acknowledges the Revised Atlanta criteria for prediction of severity. A newer Determinant-based system has been developed. The principle of surgical management of acute necrotizing pancreatitis requires intensive care management, identifying infection and if indicated, debridement of any infected necrotic area. The current procedures opted for include standard surgical open necrosectomy, endoscopic necrosectomy and minimally invasive necrosectomy. The current paradigm is shifting towards a step-up approach. CONCLUSIONS Severe acute pancreatitis is still a subject of grey areas in its surgical management even though new studies have been recorded since the origin of the latest UK guidelines for management of severe acute pancreatitis.
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18
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Mourad MM, Evans R, Kalidindi V, Navaratnam R, Dvorkin L, Bramhall SR. Prophylactic antibiotics in acute pancreatitis: endless debate. Ann R Coll Surg Engl 2017; 99:107-112. [PMID: 27917667 PMCID: PMC5392851 DOI: 10.1308/rcsann.2016.0355] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2016] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The development of pancreatic infection is associated with the development of a deteriorating disease with subsequent high morbidity and mortality. There is agreement that in mild pancreatitis there is no need to use antibiotics; in severe pancreatitis it would appear to be a logical choice to use antibiotics to prevent secondary pancreatic infection and decrease associated mortality. MATERIALS AND METHODS A non-systematic review of current evidence, meta-analyses and randomized controlled trials was conducted to assess the role of prophylactic antibiotics in acute pancreatitis and whether it might improve morbidity and mortality in pancreatitis. RESULTS Mixed evidence was found to support and refute the role of prophylactic antibiotics in acute pancreatitis. Most studies have failed to demonstrate much benefit from its routine use. Data from our unit suggested little benefit of their routine use, and showed that the mortality of those treated with antibiotics was significantly higher compared with those not treated with antibiotics (9% vs 0%, respectively, P = 0.043). In addition, the antibiotic group had significantly higher morbidity (36% vs 5%, respectively, P = 0.002). CONCLUSIONS Antibiotics should be used in patients who develop sepsis, infected necrosis-related systemic inflammatory response syndrome, multiple organ dysfunction syndrome or pancreatic and extra-pancreatic infection. Despite the many other factors that should be considered, prompt antibiotic therapy is recommended once inflammatory markers are raised, to prevent secondary pancreatic infection. Unfortunately, there remain many unanswered questions regarding the indications for antibiotic administration and the patients who benefit from antibiotic treatment in acute pancreatitis.
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Affiliation(s)
- M M Mourad
- Hereford County Hospital, Wye Valley NHS Trust , Hereford , UK
| | - Rpt Evans
- Hereford County Hospital, Wye Valley NHS Trust , Hereford , UK
| | - V Kalidindi
- North Middlesex University Hospital NHS Trust , London , UK
| | - R Navaratnam
- North Middlesex University Hospital NHS Trust , London , UK
| | - L Dvorkin
- North Middlesex University Hospital NHS Trust , London , UK
| | - S R Bramhall
- Hereford County Hospital, Wye Valley NHS Trust , Hereford , UK
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19
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Mourad MM, Evans R, Kalidindi V, Navaratnam R, Dvorkin L, Bramhall SR. Prophylactic antibiotics in acute pancreatitis: endless debate. Ann R Coll Surg Engl 2016. [PMID: 27917667 DOI: 10.1308/rcsann.2016.0355.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The development of pancreatic infection is associated with the development of a deteriorating disease with subsequent high morbidity and mortality. There is agreement that in mild pancreatitis there is no need to use antibiotics; in severe pancreatitis it would appear to be a logical choice to use antibiotics to prevent secondary pancreatic infection and decrease associated mortality. MATERIALS AND METHODS A non-systematic review of current evidence, meta-analyses and randomized controlled trials was conducted to assess the role of prophylactic antibiotics in acute pancreatitis and whether it might improve morbidity and mortality in pancreatitis. RESULTS Mixed evidence was found to support and refute the role of prophylactic antibiotics in acute pancreatitis. Most studies have failed to demonstrate much benefit from its routine use. Data from our unit suggested little benefit of their routine use, and showed that the mortality of those treated with antibiotics was significantly higher compared with those not treated with antibiotics (9% vs 0%, respectively, P = 0.043). In addition, the antibiotic group had significantly higher morbidity (36% vs 5%, respectively, P = 0.002). CONCLUSIONS Antibiotics should be used in patients who develop sepsis, infected necrosis-related systemic inflammatory response syndrome, multiple organ dysfunction syndrome or pancreatic and extra-pancreatic infection. Despite the many other factors that should be considered, prompt antibiotic therapy is recommended once inflammatory markers are raised, to prevent secondary pancreatic infection. Unfortunately, there remain many unanswered questions regarding the indications for antibiotic administration and the patients who benefit from antibiotic treatment in acute pancreatitis.
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Affiliation(s)
- M M Mourad
- Hereford County Hospital, Wye Valley NHS Trust , Hereford , UK
| | - Rpt Evans
- Hereford County Hospital, Wye Valley NHS Trust , Hereford , UK
| | - V Kalidindi
- North Middlesex University Hospital NHS Trust , London , UK
| | - R Navaratnam
- North Middlesex University Hospital NHS Trust , London , UK
| | - L Dvorkin
- North Middlesex University Hospital NHS Trust , London , UK
| | - S R Bramhall
- Hereford County Hospital, Wye Valley NHS Trust , Hereford , UK
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20
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Arlt A, Erhart W, Schafmayer C, Held HC, Hampe J. Antibiosis of Necrotizing Pancreatitis. VISZERALMEDIZIN 2015; 30:318-24. [PMID: 26286761 PMCID: PMC4513830 DOI: 10.1159/000367948] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Necrotizing pancreatitis is a life-threatening presentation of acute pancreatitis. The mortality of 20-80% initially depends on the persistence of organ failure and systemic inflammatory response syndrome (SIRS) and, in the later course of the disease, on secondary infection of the necrosis. The questions whether prophylactic antibiotics aiming to prevent this infection should be administered and which antibiotic is the best to use, as well as the problem of fungal infection under antibiotic treatment are still intriguing and insufficiently solved. METHODS A search of the literature using PubMed was carried out, supplemented by a review of the programmes of the Digestive Disease Week (DDW) and the United European Gastroenterology Week (UEGW). RESULTS Despite the widely practised prophylactic antibiotic administration in severe pancreatitis, no evidence for the benefit of this strategy exists. One of the drawbacks might be a tendency for disastrous fungal infection under prophylactic antibiotics. Bacterial translocation from the gut in the second week after the onset of symptoms is the major source for infection of pancreatic necrosis and provides a clear indication for antibiotic treatment. However, routine fine-needle aspiration for a calculated antibiotic therapy cannot be recommended, and all other tests offer only indirect signs. Important factors such as enteral versus parenteral feeding and the method of necrosectomy are mostly neglected in the trials but seem to be essential for the outcome of the patient. CONCLUSIONS Even though most meta-analyses including the newer double-blind, placebo-controlled trials on prophylactic antibiotics showed no beneficial effects in the prevention of infection of necrosis and/or outcome of the patients, this strategy is still widely used in clinical routine. Since nearly all trials published so far show systematic problems (i.e. inaccurate definition of the severity of the disease, poor statistical testing, and neglect of differences in the route of nutrition), there is a need for randomized controlled prospective trials with exact definitions of the disease.
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Affiliation(s)
- Alexander Arlt
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Wiebke Erhart
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Clemens Schafmayer
- Department of General and Thoracic Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Hanns-Christoph Held
- Department of General, Thoracic and Vascular Surgery, University Hospital Dresden, Dresden University of Technology, Dresden, Germany
| | - Jochen Hampe
- Department of Internal Medicine I, University Hospital Dresden, Dresden University of Technology, Dresden, Germany
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Yokoe M, Takada T, Mayumi T, Yoshida M, Isaji S, Wada K, Itoi T, Sata N, Gabata T, Igarashi H, Kataoka K, Hirota M, Kadoya M, Kitamura N, Kimura Y, Kiriyama S, Shirai K, Hattori T, Takeda K, Takeyama Y, Hirota M, Sekimoto M, Shikata S, Arata S, Hirata K. Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:405-432. [PMID: 25973947 DOI: 10.1002/jhbp.259] [Citation(s) in RCA: 279] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/10/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines. METHODS A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines. RESULTS Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles. CONCLUSIONS The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.
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Affiliation(s)
- Masamichi Yokoe
- General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, KitaKyushu, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Chemotherapy Research Institute, International University of Health and Welfare, Ichikawa, Japan
| | - Shuji Isaji
- Hepatobiliary Pancreatic & Transplant Surgery Mie University Graduate School of Medicine, Mie, Japan
| | - Keita Wada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Toshifumi Gabata
- Department of Radiology, Kanazawa University, School of Medical Science, Kanazawa, Japan
| | - Hisato Igarashi
- Clinical Education Center, Kyushu University Hospital, Fukuoka, Japan
| | - Keisho Kataoka
- Otsu Municipal Hospital, Shiga
- Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiko Hirota
- Department of Surgery, Kumamoto Regional Medical Center, Kumamoto, Japan
| | - Masumi Kadoya
- Department of Radiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Seiki Kiriyama
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Kunihiro Shirai
- Department of Emergency and Critical Care Medicine, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Takayuki Hattori
- Department of Radiology, Tokyo Metropolitan Health and Medical Treatment Corporation, Ohkubo Hospital, Tokyo, Japan
| | - Kazunori Takeda
- Department of Surgery, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kinki University Faculty of Medicine, Osaka, Japan
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miho Sekimoto
- The University of Tokyo Graduate School of Public Policy, Health Policy Unit, Tokyo
| | - Satoru Shikata
- Department of Family Medicine, Mie Prefectural Ichishi Hospital, Mie, Japan
| | - Shinju Arata
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Koichi Hirata
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
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Guo Q, Li A, Xia Q, Hu W. Late infection of pancreatic necrosis: A separate entity in necrotizing pancreatitis with low mortality. Pancreatology 2015; 15:360-5. [PMID: 26028333 DOI: 10.1016/j.pan.2015.05.459] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 05/05/2015] [Accepted: 05/07/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Several studies have examined on the timing of the onset of infected necrosis and organ failure. The duration of these two complications and the effects of different durations of these two complications have not been mentioned. Our aim was to investigate the durations of these two complications and the corresponding effects of the different durations. METHODS A post-hoc analysis was performed on a prospective database containing 578 patients with necrotizing pancreatitis. The patients who received intervention were divided into subgroups based on different durations of the two complications, and the outcomes were compared. RESULTS The mortality rate in patients with late infection (occurred after 30 days) was lower than in the early (infection occurred within 30 days) group (3% vs. 22%, P < 0.05). The mortality rate in patients with long duration (>7 days) of infection before intervention was similar with those patients with short duration (≤7 days) of infection (6/27 vs. 11/74; P = 0.38). The mortality rate in patients with long duration (>7 days) of organ failure before intervention was higher than in patients with short duration (≤7 days) of organ failure (31/99 vs. 18/184; P < 0.001). CONCLUSION Patients with late developed infection of pancreatic necrosis showed significantly better prognosis than patients with early infection. The duration of organ failure before intervention was correlated with mortality of necrotizing pancreatitis.
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Affiliation(s)
- Qiang Guo
- Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, 610041 Sichuan Province, China
| | - Ang Li
- Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, 610041 Sichuan Province, China
| | - Qing Xia
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, 610041 Sichuan Province, China
| | - Weiming Hu
- Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, 610041 Sichuan Province, China.
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Abstract
This Living FRISBEE (Living FRIendly Summary of the Body of Evidence using Epistemonikos) is an update of the summary published in August 2014, based on two systematic reviews appeared in January and February 2015. There is controversy about the effects of prophylactic antibiotics in acute pancreatitis. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified 18 systematic reviews including 19 randomised studies overall. We combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded that prophylactic antibiotics may reduce mortality and length of hospitalization in patients with acute pancreatitis, but the certainty of the evidence is low. The probability that future evidence change what we know is high.
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Affiliation(s)
- Gabriel Rada
- Programa de Salud Basada en Evidencia, Facultad de Medicina, Pontificia Universidad Católica de Chile; Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile; GRADE working group; The Cochrane Collaboration; Fundación Epistemonikos. Address: Facultad de Medicina, Pontificia Universidad Católica de Chile Lira 63, Santiago Centro, Chile.
| | - José Peña
- Programa de Salud Basada en Evidencia, Facultad de Medicina, Pontificia Universidad Católica de Chile; Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile; Fundación Epistemonikos
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24
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Ukai T, Shikata S, Inoue M, Noguchi Y, Igarashi H, Isaji S, Mayumi T, Yoshida M, Takemura YC. Early prophylactic antibiotics administration for acute necrotizing pancreatitis: a meta-analysis of randomized controlled trials. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:316-321. [PMID: 25678060 DOI: 10.1002/jhbp.221] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 12/25/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND The effectiveness of prophylactic antibiotics use for acute necrotizing pancreatitis has been explored and a number of systematic reviews have been published with conflicting results. The timing of antibiotics administration can be fundamental to their effectiveness, but thus far no reviews have focused on the timing of administration. METHODS A systematic review of randomized controlled trials (RCTs) of prophylactic antibiotics for acute necrotizing pancreatitis was conducted using MEDLINE (PubMed), CINAHL and Japana Centra Revuo Medicina. Trials in which antibiotics were administered within 72 h after onset of symptoms or 48 h after admission were included. Our primary outcomes were the mortality rate and the incidence of infected pancreatic necrosis, and secondary outcomes were the incidence of non-pancreatic infection and the incidence of surgical intervention. RESULTS The search revealed six RCTs with a total of 397 patients. The mortality rates were significantly different for those taking antibiotics (7.4%), and controls (14.4%) (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.25-0.94). Also, early prophylactic antibiotics use was associated with reduced incidence of infected pancreatic necrosis (antibiotics 16.3%, controls 25.1%; OR, 0.55; 95% CI, 0.33-0.92). CONCLUSION Early use of prophylactic antibiotics for acute necrotizing pancreatitis is associated with reduced mortality and lower incidence of infected pancreatic necrosis.
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Affiliation(s)
- Tomohiko Ukai
- Department of Community Medicine, Mie University School of Medicine, Tsu, Mie, Japan
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Butte JM, Hameed M, Ball CG. Hepato-pancreato-biliary emergencies for the acute care surgeon: etiology, diagnosis and treatment. World J Emerg Surg 2015; 10:13. [PMID: 25767562 PMCID: PMC4357088 DOI: 10.1186/s13017-015-0004-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 02/02/2015] [Indexed: 12/19/2022] Open
Abstract
Hepatopancreatobiliary (HPB) emergencies include an ample range of conditions with overlapping clinical presentations and diverse therapeutic options. The most common etiologies are related to cholelithiasis (acute cholecystitis, pancreatitis, and cholangitis) and non-traumatic injuries (common bile duct or duodenal). Although the true incidence of HPB emergencies is difficult to determine due to selection and reporting biases, a population-based report showed a decline in the global incidence of all severe complications of cholelithiasis, primarily based on a reduction in acute cholecystitis. Even though patients may present with overlapping symptoms, treatment options can be varied. The treatment of these conditions continues to evolve and patients may require endoscopic, surgical, and/or percutaneous techniques. Thus, it is essential that a multidisciplinary team of HPB surgeons, interventional gastroenterologists and radiologists are available on an as needed basis to the Acute Care Surgeon. This focused manuscript is a contemporary review of the literature surrounding HPB emergencies in the context of the acute care surgeon. The main aim of this review is to offer an update of the diagnosis and management of HPB issues in the acute care setting to improve the care of patients with potential HPB emergencies.
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Affiliation(s)
- Jean M Butte
- Department of Surgery, Foothills Medical Center, University of Calgary, Calgary, AB Canada
| | - Morad Hameed
- University of British Columbia, Vancouver, BC Canada
| | - Chad G Ball
- Department of Surgery, Foothills Medical Center, University of Calgary, Calgary, AB Canada
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Cunha EFDC, Rocha MDS, Pereira FP, Blasbalg R, Baroni RH. Walled-off pancreatic necrosis and other current concepts in the radiological assessment of acute pancreatitis. Radiol Bras 2015; 47:165-75. [PMID: 25741074 PMCID: PMC4337140 DOI: 10.1590/0100-3984.2012.1565] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 10/02/2013] [Indexed: 12/12/2022] Open
Abstract
Acute pancreatitis is an inflammatory condition caused by intracellular activation
and extravasation of inappropriate proteolytic enzymes determining destruction of
pancreatic parenchyma and peripancreatic tissues. This is a fairly common clinical
condition with two main presentations, namely, endematous pancreatitis - a less
severe presentation -, and necrotizing pancreatitis - the most severe presentation
that affects a significant part of patients. The radiological evaluation,
particularly by computed tomography, plays a fundamental role in the definition of
the management of severe cases, especially regarding the characterization of local
complications with implications in the prognosis and in the definition of the
therapeutic approach. New concepts include the subdivision of necrotizing
pancreatitis into the following presentations: pancreatic parenchymal necrosis with
concomitant peripancreatic tissue necrosis, and necrosis restricted to peripancreatic
tissues. Moreover, there was a systematization of the terms acute peripancreatic
fluid collection, pseudocyst, post-necrotic pancreatic/peripancreatic fluid
collections and walled-off pancreatic necrosis. The knowledge about such terms is
extremely relevant to standardize the terminology utilized by specialists involved in
the diagnosis and treatment of these patients.
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Affiliation(s)
| | - Manoel de Souza Rocha
- Private Docent, Associate Professor, Department of Radiology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Fábio Payão Pereira
- MD, Radiologist, Instituto de Radiologia - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InRad/HC-FMUSP), São Paulo, SP, Brasil
| | - Roberto Blasbalg
- PhDs, MDs, Radiologists, Instituto de Radiologia - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InRad/HC-FMUSP), São Paulo, SP, Brazil
| | - Ronaldo Hueb Baroni
- PhDs, MDs, Radiologists, Instituto de Radiologia - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InRad/HC-FMUSP), São Paulo, SP, Brazil
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Lee HS, Lee SK, Park DH, Lee SS, Seo DW, Kim MH, Chong YP. Emergence of multidrug resistant infection in patients with severe acute pancreatitis. Pancreatology 2014; 14:450-3. [PMID: 25458666 DOI: 10.1016/j.pan.2014.10.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 09/26/2014] [Accepted: 10/07/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Infection is the most important risk factor contributing to death in severe acute pancreatitis. Multidrug resistant (MDR) bacterial infections are an emerging problem in severe acute pancreatitis. METHODS From January 2009 to December 2011 the medical records of 46 patients with infected severe acute pancreatitis were reviewed retrospectively to identify risk factors for the development of MDR bacterial infection and assess the related outcomes. RESULTS The mean age of the 46 patients was 55 years; 38 were males. Thirty-six patients (78.3%) had necrotizing pancreatitis and all of enrolled 46 patients had suspected or proven pancreatic infection. MDR microorganisms was found in 29 (63%) of the 46 patients. A total of 51 episodes of MDR infection were collected from 11 cases of infected pancreatic pseudocysts, 36 cases of infected necrosis/infected walled-off necrosis and 4 cases of bacteremia. The most frequent MDR bacteria was methicillin-resistant Staphylococcus aureus (n = 15). Transferred patients had a higher incidence of MDR infections than primarily admitted patients (72% vs. 35%, P = .015). The mean intensive care unit stay was significantly longer in patients with MDR bacterial infections (20 vs. 2 days, P = .001). Mortality was not significantly different in the patients with MDR infections vs. those without it (14% vs. 6%, P = .411). CONCLUSIONS Clinicians should be aware of the high incidence of MDR bacterial infections in patients with severe acute pancreatitis, especially referred patients. Empiric therapy directed at these pathogens may be used in patients where severe sepsis persists, until definitive culture results are obtained.
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Affiliation(s)
- Ho-Su Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Koo Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Do Hyun Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Soo Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Wan Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Myung-Hwan Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Talukdar R, Ingale P, Choudhury HP, Dhingra R, Shetty S, Joshi H, Pradeep KR, Mahapatra L, Mazumder S, Pradeep JK, Thakker B, Chaudhary A, Kumar A, Nageshwar Reddy D, Rao GV, Ramesh H, Bhat N, Garg P, Kochhar R. Antibiotic use in acute pancreatitis: an Indian multicenter observational study. Indian J Gastroenterol 2014; 33:458-65. [PMID: 25138788 DOI: 10.1007/s12664-014-0494-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/02/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Prophylactic antibiotics are used frequently for acute pancreatitis (AP). Consensus guidelines do not recommend this currently, based on moderate quality evidence. In this study, we aimed to evaluate the antibiotic use pattern in AP in India and propose a risk-directed approach to antibiotic use in AP. MATERIAL AND METHODS This multicenter study was conducted from 1 May 2013 to 31 July 2013. Eleven participants from eight tertiary centers completed a questionnaire that captured patient demographics, etiology, admission status, presence of (peri)pancreatic necrosis, severity of pancreatitis, details of antibiotic use, and clinical outcomes (total hospital stay, persistent organ failure, need for ICU, total days in ICU, development of infections, in-hospital mortality). RESULTS A total of 200 proformas were analyzed. Seventy-three (36.5 %) had acute necrotizing pancreatitis (ANP). Eighty-nine (44.5 %), 52 (26 %), and 55 (27.5 %) patients had mild AP (MAP), moderately severe AP (MSAP), and severe AP (SAP), respectively. Forty-five (22.5 %) patients developed infections (unifocal 29; multifocal 16). One hundred thirty-four (67 %) patients received antibiotics, of which 89 (66.4 %) received prophylactic, while 45 (33.6 %) received therapeutic antibiotics. The distribution of antibiotic use according to the severity of AP was 43 (48.3 %) in patients with MAP (prophylactic in 41; therapeutic in 2), 36 (69.2 %) in patients with MSAP (prophylactic in 29; therapeutic in 7), and 55 (100 %) in patients with SAP (prophylactic in 19; therapeutic in 36). Therapeutic antibiotics were prescribed based on culture and sensitivity in 21 (46.7 %) patients. CONCLUSIONS Despite nonrecommendation, prophylactic antibiotics are used frequently in AP. We emphasize on the need for multicenter randomized controlled trials on prophylactic antibiotics for AP based on a risk-directed approach, rather than a "blanket approach."
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Affiliation(s)
- Rupjyoti Talukdar
- Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad, 500 082, India
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Xie FM, Zhang HR. Probiotics in treatment of severe acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2014; 22:3232-3238. [DOI: 10.11569/wcjd.v22.i22.3232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Severe acute pancreatitis (SAP) is a life-threatening condition characterized by high mortality, with infection and bacteremia being major causes of death. Prophylactic antibiotic administration failed to show any favorable effect on the incidence of infectious complications in SAP patients. Consequently, microorganism intervention is recommend by World Health Organization (WHO). Probiotics improve the prognosis of SAP patients by promoting gastrointestinal peristalsis, modulating the content of gut microbiota, maintaining the integrity of the gut barrier, modulating the immune response by the gut-associated immune system and reducing the damage to the pancreas, lung and liver. It has been demonstrated that probiotics in combination with immunonutrition could improve the prognosis of SAP patients. However, the use of probiotics in SAP remains controversial currently.
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Rebours V. [Acute pancreatitis: an overview of the management]. Rev Med Interne 2014; 35:649-55. [PMID: 24837648 DOI: 10.1016/j.revmed.2014.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Accepted: 04/15/2014] [Indexed: 12/18/2022]
Abstract
Over the past decades, the incidence and the number of hospital admissions for acute pancreatitis have increased in the Western countries. The two most common etiological factors of acute pancreatitis are gallstones (including small gallstones or microlithiasis) and alcohol abuse. Acute pancreatitis is associated with a significant mortality (4-10%) and 25% in case of pancreatic necrosis, especially. Edematous pancreatitis is benign and oral feeding can be restarted once abdominal pain is decreasing and inflammatory markers are improving. Enteral tube feeding should be the primary therapy in patients with predicted severe acute pancreatitis who require nutritional support. Enteral nutrition in acute pancreatitis can be administered via either the nasojejunal or nasogastric route. In case of necrosis, preventive antibiotics are not recommended. The single indication is infected necrosis confirmed by fine needle aspiration. The incidence trends of acute pancreatitis possibly reflect a change in the prevalence of main etiological factors (e.g. gallstones and alcohol consumption) and cofactors such as tobacco, obesity and genetic susceptibility. Priority is to search for associated causes, especially in cases with atypical symptoms. In case of first acute pancreatitis in patients older than 50 years, the presence of a tumor (benign or malignant) has to be specifically ruled out, using CT-scan, MRI and endoscopic ultrasound.
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Affiliation(s)
- V Rebours
- Service de pancréatologie, gastro-entérologie, hôpital Beaujon, 100, boulevard du Général-Leclerc, 92110 Clichy, France.
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Effects of probiotic supplementation on markers of acute pancreatitis in rats. Curr Ther Res Clin Exp 2014; 70:136-48. [PMID: 24683225 DOI: 10.1016/j.curtheres.2009.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2008] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Intestinal barrier disruption followed by bacterial translocation seems to play a role in secondary pancreatic infection in acute pancreatitis. The use of probiotics as a possible adjuvant strategy in the treatment of acute pancreatitis needs to be investigated. OBJECTIVE The aim of this study was to determine the effects of dietary supplementation with a prophylactically administered multispecies probiotic mixture on the markers of acute pancreatitis and on the occurrence of bacterial translocation. METHODS Thirty adult male Wistar rats were randomly assigned to 1 of 3 groups of 10 rats each: (1) the PS group, in which the rats were given probiotic supplementation prior to induction of acute pancreatitis; (2) the WP group, in which the rats underwent surgery to induce acute pancreatitis without prior probiotic supplementation; and (3) the control group, in which the rats underwent sham surgery. For 14 days before surgery, animals in the PS group received a single daily dose containing ~1.2 × 10(9) colony-forming units of a probiotic mixture administered intragastrically as a bolus. On day 15, the animals underwent surgery to induce acute pancreatitis (PS and WP groups) or simulated surgery (control group). Blood samples were collected to determine leukocyte count, amylase and lipase activities, and glucose and calcium concentrations immediately before and 6 and 12 hours after the beginning of the procedure. Samples of pancreas, spleen, liver, and mesenteric lymph nodes were harvested for microbiologic and histopathologic analysis after the last blood sample collection. The pathologist examining the histopathology was blinded to treatment assignment. RESULTS The mean leukocyte count was significantly increased in the PS group compared with the WP group (P = 0.018), whereas the serum amylase and lipase activities and the serum glucose and calcium concentrations were not significantly different between the 2 groups. Comparing the risk for tissue colonization in the PS group with that of the WP group, the odds ratio (OR) for pancreas was 2.91 (95% CI, 0.13-67.10); liver, 66.55 (95% CI, 1.89-2282.66); spleen, 88.58 (95% CI, 3.04-2583.08); and mesenteric lymph nodes, 1.23 (95% CI, 0.06-25.48). When the risks for histopathologic changes were compared between the 2 groups, the OR for acinar necrosis was 1.73 (95% CI, 0.21-12.17); steatonecrosis, 12.08 (95% CI, 1.26-115.54); hemorrhage, 1.38 (95% CI, 0.21-9.53); and leukocyte infiltration, 5.91 (95% CI, 0.64-54.89). CONCLUSION Probiotic supplementation before the induction of acute pancreatitis was associated with a greater degree of bacterial translocation and pancreatic tissue damage in this animal model.
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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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Bacteremia in patients with acute pancreatitis as revealed by 16S ribosomal RNA gene-based techniques*. Crit Care Med 2013; 41:1938-50. [PMID: 23863226 DOI: 10.1097/ccm.0b013e31828a3dba] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To define the characteristic of bacteremia in patients with acute pancreatitis and determine its possible association with the disease severity. DESIGN A prospective controlled study. SETTING ICU of Jinling Hospital, China. PATIENTS A total of 48 patients with mild or severe acute pancreatitis were enrolled in the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Samples of peripheral blood were collected from the patients at 4 or 5 and 9 or 10 days after acute pancreatitis was definitely diagnosed. Resulting DNA from the blood was analyzed using denaturing gradient gel electrophoresis, and separated fragments were sequenced for identification of bacterial species. Bacterial DNA was detected in peripheral blood from 68.8% of patients with acute pancreatitis, and more than half (60.4%) of the patients encountered polymicrobial flora. Translocated bacteria in patients with acute pancreatitis were primarily constituted of opportunistic pathogens derived from the gut, including Escherichia coli, Shigella flexneri, Enterobacteriaceae bacterium, Acinetobacter lwoffii, Bacillus coagulans, and Enterococcus faecium. The species of circulating bacteria shifted remarkably among the patients with different severity. The presence of the bacteremia correlated positively with the Acute Physiology and Chronic Health Evaluation-II scores of patients with acute pancreatitis (r = 0.7918, p < 0.0001). CONCLUSIONS This study provides a detailed description on the prevalence of bacteremia and characteristic of bacterial species in patients with acute pancreatitis. We demonstrate an association between the bacteremia and the disease severity, which enables us to better understand a potential role of bacterial translocation in the pathogenesis of septic complication in acute pancreatitis.
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The role of open necrosectomy in the current management of acute necrotizing pancreatitis: a review article. ISRN SURGERY 2013; 2013:579435. [PMID: 23431472 PMCID: PMC3569915 DOI: 10.1155/2013/579435] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 01/07/2013] [Indexed: 12/12/2022]
Abstract
The optimal management of necrotizing pancreatitis continues to evolve. Currently, conservative intensive care treatment represents the primary therapy of acute severe necrotizing pancreatitis, aiming at prevention of organ failure. Following this mode of treatment most patients with sterile necroses can be managed successfully. Surgery might be considered as an option in the late phase of the disease for patients with proven infected pancreatic necroses and organ failure. For these patients surgical debridement is still considered the treatment of choice. However, even for this subgroup of patients, the concept of operative strategy has been recently challenged. Nowadays, it is generally accepted that necrotizing pancreatitis with proven infected necroses as well as septic complications directly caused by pancreatic infection are strong indications for surgical management. However, the question of the most appropriate surgical technique for the treatment of pancreatic necroses remains unsettled. At the same time, recent advances in radiological imaging, new developments in interventional radiology, and other minimal access interventions have revolutionised the management of necrotizing pancreatitis. In light of these controversies, the present paper will focus on the current role of surgery in terms of open necrosectomy in the management of severe acute necrotizing pancreatitis.
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Ignatavicius P, Vitkauskiene A, Pundzius J, Dambrauskas Z, Barauskas G. Effects of prophylactic antibiotics in acute pancreatitis. HPB (Oxford) 2012; 14:396-402. [PMID: 22568416 PMCID: PMC3384864 DOI: 10.1111/j.1477-2574.2012.00464.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 02/24/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The use of prophylactic antibiotics in severe acute pancreatitis (SAP) is controversial. The aim of this study was to compare the effects of antibiotics administered as prophylaxis and as treatment on demand, respectively, in two prospective, non-randomized cohorts of patients. METHODS The study population consisted of 210 patients treated for SAP. In Group 1 (n= 103), patients received prophylactic antibiotics (ciprofloxacin, metronidazole). In Group 2 (n= 107), patients were treated on demand. Ultrasound-guided drainage and/or surgical debridement of infected necrosis were performed when the presence of infected pancreatic necrosis was demonstrated. The primary endpoints were infectious complication rate, need for and timing of surgical interventions, incidence of nosocomial infections and mortality rate. RESULTS Ultrasound-guided fine needle aspiration [in 18 (16.8%) vs. 13 (12.6%) patients; P= 0.714], ultrasound-guided drainage [in 15 (14.0%) vs. six (5.8%) patients; P= 0.065] and open surgical necrosectomy [in 10 (9.3%) vs. five (4.9%) patients; P= 0.206] were performed more frequently and earlier [at 16.6 ± 7.8 days vs. 17.2 ± 6.7 days (P= 0.723); at 19.5 ± 9.4 days vs. 24.5 ± 14.2 days (P= 0.498), and at 22.6 ± 13.5 days vs. 26.7 ± 18.1 days (P= 0.826), respectively] in Group 2 compared with Group 1. There were no significant differences between groups in mortality and duration of stay in the surgical ward or intensive care unit. CONCLUSIONS The results of this study support the suggestion that the use of prophylactic antibiotics does not affect mortality rate, but may decrease the need for interventional and surgical management, and lower the number of reoperations.
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Affiliation(s)
- Povilas Ignatavicius
- Department of Surgery, Institute for Digestive System Research, Lithuanian University of Health SciencesKaunas, Lithuania
| | - Astra Vitkauskiene
- Department of Laboratory Medicine, Institute for Digestive System Research, Lithuanian University of Health SciencesKaunas, Lithuania
| | - Juozas Pundzius
- Department of Surgery, Institute for Digestive System Research, Lithuanian University of Health SciencesKaunas, Lithuania
| | - Zilvinas Dambrauskas
- Department of Surgery, Institute for Digestive System Research, Lithuanian University of Health SciencesKaunas, Lithuania
- Department of Laboratory of Surgical Gastroenterology, Institute for Digestive System Research, Lithuanian University of Health SciencesKaunas, Lithuania
| | - Giedrius Barauskas
- Department of Surgery, Institute for Digestive System Research, Lithuanian University of Health SciencesKaunas, Lithuania
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Rao CY, Hu CL, Zhao XY. Role of prophylactic antibiotics in the management of acute necrotizing pancreatitis: A meta-analysis. Shijie Huaren Xiaohua Zazhi 2012; 20:1246-1251. [DOI: 10.11569/wcjd.v20.i14.1246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the role of prophylactic antibiotics in the management of acute necrotizing pancreatitis.
METHODS: A computerized literature search of Medline, PubMed, Spring, Ovid, Elsevier, Embase, CNKI, and VIP databases was conducted to identify relevant articles published from January 1994 to October 2011. According to the inclusion criteria, 5 studies were selected. The data were analyzed using RevMan 5.1 software.
RESULTS: Our meta-analysis suggests that prophylactic antibiotic treatment did not significantly reduce morbility (RR = 0.75, 95%CI 0.43-1.28, P = 0.29) or the incidence of infected pancreatic necrosis (RR = 0.81, 95%CI 0.55-1.19, P = 0.29), nonpancreatic infection (RR = 0.79, 95%CI 0.59-1.06, P = 0.12), or surgical intervention (RR = 0.78, 95%CI 0.45-1.36, P = 0.37).
CONCLUSION: Prophylactic antibiotic treatment does not reduce the occurrence of infected pancreatic necrosis, nonpancreatic infection, surgical intervention or morbility in patients with acute necrotizing pancreatitis.
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Risk of bacterial colonization of pancreatic stents used in endoscopic retrograde cholangiopancreatography. J Clin Gastroenterol 2012; 46:324-7. [PMID: 22138843 DOI: 10.1097/mcg.0b013e31823712cc] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Pancreatic stents (PSs) are commonly inserted at the time of endoscopic retrograde cholangiopancreatography to reduce the risk of pancreatitis. If left in situ for more than 2 weeks, they have been associated with pancreatic duct injury. The mechanism of this injury is not clear, but it may be related to bacterial colonization. AIM : To determine the incidence of PS colonization by microorganisms and the relationship between such colonization and the type, length, diameter, and duration of PSs in situ. METHODS A series of endoscopic retrograde cholangiopancreatographies performed by a single operator in a tertiary referral centre during which a PS was placed was analysed. In each case, after removing the PS, the segment of the PS, which had been intraluminal, was sent for microbiological analysis. Microscopy and culture results were compared with stent length (cm), time in situ (d), demographic information, and clinical course. RESULTS Of the 47 PSs sent for culture, 28 grew clinically significant bacteria. The majority of organisms cultured were of the Klebsiella, Escherichia, Enterobacter, and Enterococcus genera. Time in situ was found to correlate strongly with the growth of clinically significant organisms using a logarithmic regression analysis tool (coefficient=0.36, change of variance=6.43, P=0.01). In addition, 1 patient developed Enterobacter septicaemia almost certainly related to stent colonization, which necessitated urgent removal of the stent 10 days after insertion. CONCLUSION Colonization of PSs by pathogenic organisms is common and related to duration in situ of the PS. Enteric organisms are frequently implicated. Although significant clinical sequelae are infrequent, we suggest that PSs should not be left in situ for >7 to 10 days due to the significant risk of bacterial colonization.
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Jiang K, Huang W, Yang XN, Xia Q. Present and future of prophylactic antibiotics for severe acute pancreatitis. World J Gastroenterol 2012; 18:279-84. [PMID: 22294832 PMCID: PMC3261546 DOI: 10.3748/wjg.v18.i3.279] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 08/12/2011] [Accepted: 10/14/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the role of prophylactic antibiotics in the reduction of mortality of severe acute pancreatitis (SAP) patients, which is highly questioned by more and more randomized controlled trials (RCTs) and meta-analyses.
METHODS: An updated meta-analysis was performed. RCTs comparing prophylactic antibiotics for SAP with control or placebo were included for meta-analysis. The mortality outcomes were pooled for estimation, and re-pooled estimation was performed by the sensitivity analysis of an ideal large-scale RCT.
RESULTS: Currently available 11 RCTs were included. Subgroup analysis showed that there was significant reduction of mortality rate in the period before 2000, while no significant reduction in the period from 2000 [Risk Ratio, (RR) = 1.01, P = 0.98]. Funnel plot indicated that there might be apparent publication bias in the period before 2000. Sensitivity analysis showed that the RR of mortality rate ranged from 0.77 to 1.00 with a relatively narrow confidence interval (P < 0.05). However, the number needed to treat having a minor lower limit of the range (7-5096 patients) implied that certain SAP patients could still potentially prevent death by antibiotic prophylaxis.
CONCLUSION: Current evidences do not support prophylactic antibiotics as a routine treatment for SAP, but the potentially benefited sub-population requires further investigations.
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Abstract
Acute pancreatitis is a common cause of hospitalization and a major source of morbidity worldwide. When it is severe, and especially when it progresses to include necrosis of the pancreas, the risk of infection rises and mortality increases. Early reports suggested prophylactic antibiotics given in severe pancreatitis prevent infection and death. More recent clinical trials do not support this benefit, and meta-analyses on the topic offer conflicting recommendations. In this article, we evaluate the body of published literature examining the use of antibiotics as a preventive measure in acute pancreatitis. The highest quality, currently available data fail to support prophylactic use of antibiotics, which should be added to treatment regimens only where infection has been proven.
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The role of antibiotics in the management of patients with acute necrotizing pancreatitis. Curr Infect Dis Rep 2011; 12:13-8. [PMID: 21308495 DOI: 10.1007/s11908-009-0071-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Our understanding of the role of antibiotics in the management of patients with pancreatic necrosis has changed over the past 5 years. Initial studies suggested that antibiotics were useful in preventing infection of necrosis, septic complications, and mortality in patients with acute pancreatitis; however, more recent, better-designed studies established that prophylactic antibiotics are not helpful. In the absence of infection, sterile necrosis is treated conservatively. With insufficient evidence to recommend antibiotics, these agents should be reserved to treat established infection of pancreatic necrosis. Infected necrosis is treated by targeting microbes with pancreatic-penetrating antibiotics (eg, carbapenems, quinolones in combination with metronidazole, or high-dose cephalosporins). If the patient with infected necrosis remains septic or deteriorates, surgical intervention should be performed urgently. Stable patients with infected necrosis can be managed more conservatively in a closely monitored environment. Recent studies suggest that many patients can clear the infection with antibiotics, but even if they do not clear the infection, delay in surgery decreases the mortality rate. Delaying surgery by using antibiotics may allow use of less invasive procedures if drainage is needed. The timing and method of interventions must be individualized based on the patient's condition, anatomic complications, patient's preference after informed consent, and expertise available at the institution.
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Abstract
Intra-abdominal infections of pancreatic or peripancreatic necrotic tissue complicate the clinical course of severe acute pancreatitis (SAP) and are associated with significant morbidity. Fungal infection of necrotic pancreatic tissue is increasingly being reported. The incidence of intra-abdominal pancreatic fungal infection (PFI) varies from 5% to 68.5%. Candida albicans is the most frequently isolated fungus in patients with necrotizing pancreatitis. Prolonged use of prophylactic antibiotics, prolonged placement of chronic indwelling devices, and minimally invasive or surgical interventions for pancreatic fluid collections further increase the risk of PFI. Computed tomography- or ultrasound-guided fine-needle aspiration of pancreatic necrosis is a safe, reliable method for establishing pancreatic infection. Amphotericin B appears to be the most effective antifungal treatment. Drainage and debridement of infected necrosis are also critical for eradication of fungi from the poorly perfused pancreatic or peripancreatic tissues where the antifungal agents may not reach to achieve therapeutic levels. Fungal infection adversely affects the outcome of patients with SAP and is associated with increased morbidity, although the mortality rate is not increased specifically because of PFI. Although antifungal prophylaxis has been suggested for patients on broad-spectrum antibiotics, no randomized controlled trials have yet studied its efficacy in preventing PFI.
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Eckmann C, Dryden M, Montravers P, Kozlov R, Sganga G. Antimicrobial treatment of "complicated" intra-abdominal infections and the new IDSA guidelines ? a commentary and an alternative European approach according to clinical definitions. Eur J Med Res 2011; 16:115-26. [PMID: 21486724 PMCID: PMC3352208 DOI: 10.1186/2047-783x-16-3-115] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 02/25/2011] [Indexed: 01/27/2023] Open
Abstract
Recently, an update of the IDSA guidelines for the treatment of complicated intraabdominal infections has been published. No guideline can cater for all variations in ecology, antimicrobial resistance patterns, patient characteristics and presentation, health care and reimbursement systems in many different countries. In the short time the IDSA guidelines have been available, a number of practical clinical issues have been raised by physicians regarding interpretation of the guidelines. The main debatable issues of the new IDSA guidelines are described as follows: The authors of the IDSA guidelines present recommendations for the following subgroups of "complicated" IAI: community-acquired intra-abdominal infections of mild-to-moderate and high severity and health care-associated intra-abdominal infections (no general treatment recommendations, only information about antimicrobial therapy of specific resistant bacterial isolates). From a clinical point of view, "complicated" IAI are better differentiated into primary, secondary (community-acquired and postoperative) and tertiary peritonitis. Those are the clinical presentations of IAI as seen in the emergency room, the general ward and on ICU. Future antibiotic treatment studies of IAI would be more clinically relevant if they included patients in studies for the efficacy and safety of antibiotics for the treatment of the above mentioned forms of IAI, rather than conducting studies based on the vague term "complicated" intra-abdominal infections. - The new IDSA guidelines for the treatment of resistant bacteria fail to mention many of new available drugs, although clinical data for the treatment of "complicated IAI" with new substances exist. Furthermore, treatment recommendations for cIAI caused by VRE are not included. This group of diseases comprises enough patients (i.e. the entire group of postoperative and tertiary peritonitis, recurrent interventions in bile duct surgery or necrotizing pancreatitis) to provide specific recommendations for such antimicrobial treatment. - A panel of European colleagues from surgery, intensive care, clinical microbiology and infectious diseases has developed recommendations based on the above mentioned clinical entities with the aim of providing clear therapeutic recommendations for specific clinical diagnoses. An individual patient-centered approach for this very important group of diseases with a substantial morbidity and mortality is essential for optimal antimicrobial treatment.
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Affiliation(s)
- Christian Eckmann
- Klinikum Peine gGmbH, Academic Hospital of Medical University Hannover, Virchowstrasse 8h, 31226 Peine, Germany.
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Wittau M, Mayer B, Scheele J, Henne-Bruns D, Dellinger EP, Isenmann R. Systematic review and meta-analysis of antibiotic prophylaxis in severe acute pancreatitis. Scand J Gastroenterol 2011; 46:261-70. [PMID: 21067283 DOI: 10.3109/00365521.2010.531486] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The incidence of acute pancreatitis varies from 5 to 80 per 100,000 throughout the world. The most common cause of death in these patients is infection of pancreatic necrosis by enteric bacteria, spurring the discussion of whether or not prophylactic antibiotic administration could be a beneficial approach. In order to provide evidence of the effect of antibiotic prophylaxis in severe acute pancreatitis (SAP) we performed an updated systematic review and meta-analysis on this topic. METHODS The review of randomized controlled trials was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. We conducted a search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. For assessment of the treatment effects we calculated the risk ratios (RRs) for dichotomous data of included studies. RESULTS Fourteen trials were included with a total of 841 patients. The use of antibiotic prophylaxis was not associated with a statistically significant reduction in mortality (RR 0.74 [95% CI 0.50-1.07]), in the incidence of infected pancreatic necrosis (RR 0.78 [95% CI 0.60-1.02]), in the incidence of non-pancreatic infections (RR 0.70 [95% CI 0.46-1.06]), and in surgical interventions (RR 0.93 [95% CI 0.72-1.20]). CONCLUSION In summary, to date there is no evidence that supports the routine use of antibiotic prophylaxis in patients with SAP.
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Affiliation(s)
- Mathias Wittau
- Department of General, Visceral and Transplantation Surgery, University Hospital Ulm, Steinhoevelstrasse 9, Ulm, Germany.
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Abstract
OBJECTIVE Develop a swine model of secondary infection in severe acute pancreatitis (SAP). METHODS Twenty-seven female swine were divided into 3 groups (1-3). In the first experiment, a SAP model was developed by retrograde injection of sodium taurocholate and trypsin into the pancreatic duct. In the second experiment, the SAP model was used to develop a secondary infection model. In groups 1 to 3, 10⁸/mL or 10⁴/mL Escherichia coli or saline were respectively used to inoculate necrotic areas of the pancreas using computed tomographic guidance. Biochemical, histopathological, and imaging analyses were used to characterize disease presentation. RESULTS The survival rate was 85.2% (23/27) during the course of the 9-day experiment. The secondary infection rates in groups 1 to 3 were 100% (8/8), 37.5% (3/8), and 14.3% (1/7), respectively. In group 1, the infection rate was significantly higher in comparison to the other 2 groups (χ²=4.66 and 8.14, respectively, and both P<0.05). The biochemical and histopathological parameters and computed tomographic images indicated successful development of the SAP secondary infection model. CONCLUSIONS The swine model of SAP secondary infection was successfully developed using a 2-step method, which could serve as a platform for SAP studies that need complex experimental manipulations for longer time spans, especially for imaging research.
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Abstract
Acute pancreatitis (AP) is an important cause of morbidity and mortality worldwide and the annual incidence appears to be increasing. It presents as a mild self-limiting illness in 80% of patients. However, one-fifth of these develop a severe complicated life-threatening disease requiring intensive and prolonged therapeutic intervention. Alcohol and gallstone disease remain the commonest causes of AP but metabolic abnormalities, obesity and genetic susceptibility are thought be increasingly important aetiological factors. The prompt diagnosis of AP and stratification of disease severity is essential in directing rapid delivery of appropriate therapeutic measures. In this review, the range of diagnostic and prognostic assays, severity scoring systems and radiological investigations used in current clinical practice are described, highlighting their strengths and weaknesses. Increased understanding of the complex pathophysiology of AP has generated an array of new potential diagnostic assays and these are discussed. The multidisciplinary approach to management of severe pancreatitis is outlined, including areas of controversy and novel treatments.
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Affiliation(s)
- Simon J F Harper
- Department of Pancreaticobiliar Surgery, Luton & Dunstable NHS Foundation Trust, Lewsey Road, Luton, LU4 0DZ, UK.
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Zhang MM, Cheng JQ, Lu YR, Yi ZH, Yang P, Wu XT. Use of pre-, pro- and synbiotics in patients with acute pancreatitis: A meta-analysis. World J Gastroenterol 2010; 16:3970-8. [PMID: 20712060 PMCID: PMC2923773 DOI: 10.3748/wjg.v16.i31.3970] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the clinical outcomes of pre-, pro- and synbiotics therapy in patients with acute pancreatitis.
METHODS: The databases including Medline, Embase, the Cochrane Library, Web of Science and Chinese Biomedicine Database were searched for all relevant randomized controlled trials that studied the effects of pre-, pro- or synbiotics in patients with acute pancreatitis. Main outcome measures were postoperative infections, pancreatic infections, multiple organ failure (MOF), systemic inflammatory response syndrome (SIRS), length of hospital stay, antibiotic therapy and mortality.
RESULTS: Seven randomized studies with 559 acute pancreatic patients were included. Pre-, pro- or synbiotics treatment showed no influence on the incidence of postoperative infections [odds ratios (OR) 0.30, 95% confidence interval (CI): 0.09-1.02, P = 0.05], pancreatic infection (OR 0.50, 95% CI: 0.12-2.17, P = 0.36), MOF (OR 0.88, 95% CI: 0.35-2.21, P = 0.79) and SIRS (OR 0.78, 95% CI: 0.20-2.98, P = 0.71). There were also no significant differences in the length of antibiotic therapy (OR 0.75, 95% CI: 0.50-1.14, P = 0.18) and the mortality (OR 0.75, 95% CI: 0.25-2.24, P = 0.61). However, Pre-, pro- or synbiotics treatment was associated with a reduced length of hospital stay (OR -3.87, 95% CI: -6.20 to -1.54, P = 0.001). When stratifying for the severity of acute pancreatitis, the main results were similar.
CONCLUSION: Pre-, pro- or synbiotics treatment shows no significant influence on patients with acute pancreatitis. There is a lack of evidence to support the use of probiotics/synbiotics in this area.
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Imaging of acute pancreatitis: prognostic value of computed tomographic findings. J Comput Assist Tomogr 2010; 34:485-95. [PMID: 20657214 DOI: 10.1097/rct.0b013e3181d344ca] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Although most cases of acute pancreatitis are uncomplicated and resolve spontaneously, the presence of complications has significant prognostic importance. Necrosis, hemorrhage, and infection convey up to 25%, 52%, and 80% mortality, respectively. Other complications such as pseudocyst formation, pseudoaneurysm formation, or venous thrombosis increase morbidity and mortality to a lesser degree.We review the computed tomographic findings of complications associated with acute pancreatitis with emphasis on their prognostic significance and impact on clinical management.
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Chen P, Hu B, Tan Q, Liu L, Li D, Jiang C, Wu H, Li J, Tang C. Role of neurocrine somatostatin on sphincter of Oddi contractility and intestinal ischemia reperfusion-induced acute pancreatitis in macaques. Neurogastroenterol Motil 2010; 22:935-e240. [PMID: 20497509 DOI: 10.1111/j.1365-2982.2010.01506.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intestinal ischemia-reperfusion (IIR) is implicated in the pathogenesis of severe acute pancreatitis (SAP). This study investigates the impact of neurocrine somatostatin (SST) on the contraction of sphincter of Oddi (SO) during IIR. METHODS Intestinal ischemia-reperfusion model in macaques was induced by occluding the superior mesenteric artery. Pancreatitis was confirmed by pancreatic histology and serum levels of amylase and lipase. SST and its receptors (SSTRs) in SO were visualized by immunohistochemistry. Effects of SST on the contraction of the isolated SO were recorded in vitro. KEY RESULTS Inflammatory scores of the pancreas and serum levels of amylase or lipase in the macaques that underwent IIR were significantly higher than those in the control group. The frequency and amplitude of phasic contraction of the circular muscle in SO was increased by SST in a concentration-dependent manner. Compared with the control group, SST innervation or SSTR2 expression in SO of macaques treated with IIR was increased 5.2 fold or 5.6 fold respectively. Prophylactic infusion of SST before IIR significantly reduced SST immunoreactive fibers in SO as compared to those in the IIR group and remarkably alleviated the pathophysiologic changes due to IIR. CONCLUSIONS & INFERENCES Increased SST innervation in SO during the early phase of IIR associated with the contraction of circular muscle of SO, which might be one of the promoting factors associated with the development of SAP. Prevention of IIR or intervention of SO contraction after occurrence of acute pancreatitis might be beneficial for preventing SAP.
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Affiliation(s)
- P Chen
- Department of Gastroenterology, West China Hospital, Chengdu, China
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