Acute Necrotizing Pancreatitis Research Articles

Construction and Validation of a Rat Model of Acute Necrotizing Pancreatitis-Associated Intestinal Injury.

Acute pancreatitis (AP) is an acute inflammatory reaction of the pancreatic tissue, which involves auto-digestion, oedema, haemorrhage, and necrosis. AP can be categorized into mild, moderately severe and severe AP, with severe pancreatitis also referred to as acute necrotizing pancreatitis (ANP). ANP is characterized by the accumulation of necrotic material in the peritoneal cavity. This can result in intestinal injury. However, the mechanism of ANP-associated intestinal injury remains unclear. We established an ANP-associated intestinal injury rat model (ANP-IR model) by injecting pancreatitis-associated ascites fluid (PAAF) and necrotic pancreatic tissue at various proportions into the triangular area formed by the left renal artery and ureter. The feasibility of the ANP-IR model was verified by comparing the similar changes in indicators of intestinal inflammation and barrier function between the two rat models. In addition, we detected changes in apoptosis levels and YAP protein expression in the ileal tissues of rats in each group and validated them in vitro in rat epithelial crypt cells (IEC-6) to further explore the potential injury mechanisms of ANP-associated intestinal injury. We also collected clinical data from patients with ANP to validate the effects of PAAF and pancreatic necrosis on intestinal injury. Our findings offer a theoretical basis for restricting the buildup of peritoneal necrosis in individuals with ANP, thus promoting the restoration of intestinal function and enhancing treatment efficacy. The use of the ANP-IR model in further studies can help us better understand the mechanism and treatment of ANP-associated intestinal injury.

Tracking Wall Characteristics of Necrotic Pancreatic Fluid Collections in Acute Pancreatitis on Serial Contrast-Enhanced Computed Tomography

Abstract Background Encapsulated pancreatic fluid collection (PFC) is a requisite for endoscopic drainage procedures. The 4-week threshold for defining walled-off necrosis does not capture the dynamic process of encapsulation. We aim to investigate the changes in the wall characteristics of PFC in acute necrotizing pancreatitis (ANP) by comparing baseline contrast-enhanced computed tomography (CECT) with follow-up CT scans. Methods This retrospective study comprised consecutive patients with ANP who underwent a baseline CECT within first 2 weeks and follow-up CECT in the third to fifth weeks of illness. Presence, extent, and encapsulation thickness (defined as enhancing wall around the collection) on baseline CECT were compared with follow-up CT (done in the third–fifth weeks of illness). Results Thirty patients (19 males and 11 females; mean age 41.5 ± 13.5 years) were included in the study. The mean time to first CECT was 10 ± 3.6 days. There were 58 collections. The most common site was the lesser sac (n = 29), followed by the left pararenal space (n = 15). At baseline CT, 52 (89.7%) collections had varying degree of encapsulation (15.3%, complete encapsulation). Complete encapsulation was seen in 52 and 82.6% collections in third and fourth week, respectively. All collections in fifth week and beyond were encapsulated. The wall was thicker on follow-up CECT scans (p < 0.01). The mean wall thickness was not significantly associated with the degree of encapsulation (p = 0.417). There was no significant association between the site and degree of encapsulation (p = 0.546). Conclusion Encapsulation is dynamic and collections may get “walled off” before 4 weeks. Walled-off collections should be defined based on imaging rather than a fixed 4-week revised Atlanta classification threshold.

Early Endoscopic Interventions for Pancreatic Necrosis: Indications, Technique, and Outcomes.

Endoscopic transmural drainage is usually performed for symptomatic well-encapsulated walled-off necrosis (WON) that usually develops in the delayed phase (> 4weeks after disease onset) of acute necrotising pancreatitis (ANP). Endoscopic drainage is usually not advocated in the early (< 4weeks after disease onset) stage of illness because of the risk of complications due to an incompletely formed encapsulating wall and poor demarcation of viable from necrotic tissue. However, emerging data from expert tertiary care centres over the last few years shows that the early endoscopic transluminal drainage approach is effective and safe. The development of lumen-apposing metal stents and better accessories for endoscopic necrosectomy has fuelled the expansion of indications of endoscopic drainage of pancreatic necrosis. However, early endoscopic drainage is associated with higher rates of adverse events; therefore, careful patient selection is paramount. This article will review the current indications, techniques and outcomes of early endoscopic transluminal drainage in pancreatic necrotic collections.

Acute Necrotizing Pancreatitis Complicated With Sinistral Portal Hypertension And Mechanical Obstruction Of The Colon: A Case Report.

Acute necrotizing pancreatitis (ANP) is often associated with acute necrotic collection (ANC) or walled-off necrosis (WON). Due to the close anatomical connection between the pancreas, the spleen, and the transverse colon, necrotizing pancreatitis is often combined with spleen or colon involvement. Gastrointestinal dysfunction usually caused by pancreatitis leads to paralytic intestinal obstruction. However, pancreatitis combined with mechanical colonic obstruction is extremely rare. It can easily be misdiagnosed as malignant intestinal obstruction, and diagnosing the cause of intestinal obstruction becomes more critical when accompanied by Sinistral portal hypertension (SPH). Surgical resection is the primary method for the previous occurrence of colonic complications. In this case report, upon admission, a 37-year-old patient was diagnosed with acute necrotizing pancreatitis with sinistral portal hypertension. On the 6th day after admission, the patient developed a sudden colonic obstruction. After identifying the cause, the patient underwent a transanal decompression tube and minimally invasive necrosectomy, avoiding colon resection. In acute necrotizing pancreatitis combined with colonic mechanical obstruction, it is essential to clarify the etiology, and focus treatment on clearing the peripancreatic necrotic tissue, non-surgical treatment to deal with colonic obstruction is feasible, and the principle of individualized treatment should be used throughout the disease.

A Core Outcome Set for Acute Necrotizing Pancreatitis: an Eastern Association for the Surgery of Trauma Modified Delphi Method Consensus Study.

The management of acute necrotizing pancreatitis (ANP) has changed dramatically over the past 20 years including the use of less invasive techniques, the timing of interventions, nutritional management, and anti-microbial management. This study sought to create a core outcome set (COS) to help shape future research by establishing a minimal set of essential outcomes that will facilitate future comparisons and pooling of data, while minimizing reporting bias. A modified Delphi process was performed though involvement of ANP content experts. Each expert proposed a list of outcomes for consideration and the panel anonymously scored the outcomes on a 9-point Likert scale. Core outcome consensus defined a priori as >70% of scores receiving 7-9 points and < 15% of scores receiving 1-3 points. Feedback and aggregate data were shared between rounds with inter-class correlation trends used to determine the end of the study. A total of 19 experts agreed to participate in the study with 16 (84%) participating through study completion. Forty-three outcomes were initially considered with 16 reaching consensuses after four rounds of the modified Delphi process. The final COS included outcomes related to mortality, organ failure, complications, interventions/management, and social factors. Through an iterative consensus process, content experts agreed on a COS for the management of ANP. This will help shape future research to generate data suitable for pooling and other statistical analyses that may guide clinical practice. Diagnostic Tests or Criteria. Diagnostic test or criteria, V.

Immune-Enhancing Treatment among Acute Necrotizing Pancreatitis Patients with Metabolic Abnormalities: A Post Hoc Analysis of a Randomized Clinical Trial.

: Metabolic syndrome is common in patients with acute pancreatitis and its components have been reported to be associated with infectious complications. In this post hoc analysis, we aimed to evaluate whether metabolic abnormalities impact the effect of immune-enhancing thymosin alpha-1 (Tα1) therapy in acute necrotizing pancreatitis (ANP) patients. : All data were obtained from the database for a multicenter randomized clinical trial that evaluated the efficacy of Tα1 in ANP patients. Patients who discontinued the Tα1 treatment prematurely were excluded. The primary outcome was 90-day infected pancreatic necrosis (IPN) after randomization. Three post hoc subgroups were defined based on the presence of hyperglycemia, hypertriglyceridemia, or both at the time of randomization. In each subgroup, the correlation between Tα1 and 90-day IPN was assessed using the Cox proportional-hazards regression model. Multivariable propensity-score methods were used to control potential bias. : Overall, 502 participants were included in this post hoc analysis (248 received Tα1 treatment and 254 received matching placebo treatment). Among them, 271 (54.0%) had hyperglycemia, 371 (73.9%) had hypertriglyceridemia and 229 (45.6%) had both. Tα1 therapy was associated with reduced incidence of IPN among patients with hyperglycemia (18.8% vs 29.7%: hazard ratio, 0.80; 95% confidence interval, 0.37 to 0.97; p=0.03), but not in the other subgroups. Additional multivariate regression models using three propensity-score methods yielded similar results. : Among ANP patients with hyperglycemia, immune-enhancing Tα1 treatment was associated with a reduced risk of IPN (ClinicalTrials.gov, Registry number: NCT02473406).

A313 DISCONNECTED PANCREATIC DUCT SYNDROME: A RETROSPECTIVE OBSERVATIONAL STUDY REVIEWING AN IMPORTANT BUT OVERLOOKED COMPLICATION OF NECROTIZING PANCREATITIS

Abstract Background Disconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis (ANP) characterized by a complete disruption of the main pancreatic duct, leading to the loss of continuity between the pancreatic duct and the gastrointestinal tract (figure 1). Due to unopposed leakage of residual pancreatic fluid, patients with DPDS often experience a prolonged disease course with significant morbidity, including complications such as pancreatic fistulas. However, information about the epidemiology, clinical characteristics, and outcomes of DPDS remains scarce. Aims To assess clinical outcomes, diagnostic delay, burden of endoscopic and surgical interventions, and complications related to DPDS. Methods A retrospective review was conducted for all patients diagnosed with DPDS who underwent either endoscopic ultrasound (EUS) or endoscopic retrograde cholangiopancreatography (ERCP) at our tertiary center between January 2010 and December 2022. Results Fifteen patients with DPDS following ANP were identified. The median age of patients at DPDS diagnosis was 56 years (range 33-86 years), with 47% being female. The most common etiology of ANP was biliary (40%), followed by idiopathic (33%) and alcoholic (27%). The median time between ANP diagnosis and DPDS diagnosis was 265 days (range 86-2023 days). Patients underwent a median of 3 (1-9) endoscopic interventions and 1 (0-5) surgical intervention between the initial ANP episode and DPDS diagnosis. 40% of patients experienced intra-abdominal sepsis secondary to infected pancreatic fluid collections. 20% developed pancreatic fistulas (two small bowel fistulas and one cutaneous fistula). 20% developed new-onset diabetes, and 13% had significant worsening of pre-existing diabetes. No mortalities were reported. Conclusions There is a significant delay in diagnosing DPDS following ANP, and a substantial burden of endoscopic interventions is required. Frequent complications of DPDS were pancreatic fistulas, recurrent pancreatic fluid collections, and pancreatogenic diabetes. Developing a predictive model for assessing the risk of DPDS development following ANP could aid in earlier diagnosis and potentially reduce morbidity and complications associated with DPDS. Figure 1. Contrast enhanced CT demonstrating typical finding in DPDS in coronal (A) and axial (B) views. CT demonstrates 3cm area of necrosis involving pancreatic neck/body (asterisk) with viable upstream parenchyma in the remainder of the body and tail (white arrow). Pancreatic head/uncinate parenchyma and main duct appear intact (black arrow). B, the distal pancreatic duct is not dilated. DPDS, disconnected pancreatic duct syndrome. Funding Agencies None

A316 ACUTE NECROTIZING PANCREATITIS COMPLICATED BY PULMONARY EMBOLISM: A CASE REPORT AND REVIEW OF LITERATURE

Abstract Background Acute pancreatitis (AP) is an inflammatory condition associated with local and systemic complications. Severe pancreatitis can include the development of peripancreatic fluid collections and necrotizing pancreatitis (NP). Vascular complications are one of the causes of morbidity and mortality in patients with AP. Splanchnic thrombosis has been well described in AP and can been seen in up to 24% of patients. Extra splanchnic vessel thrombosis, including pulmonary embolism (PE), is rare. Aims Describe a case of acute NP with peripancreatic fluid collection complicated with bilateral PE and review the relevant literature. Methods We performed a literature review for AP complicated by PE. Results Case: A 60-year-old man presented to the hospital with one day of abdominal pain, nausea and vomiting. His medical history was significant for obesity with a BMI of 40. He was not on any medications. He did not drink alcohol. On exam his heart rate was 58, blood pressure 149/94 mmHG, oxygen saturation was 95% on room air, he was afebrile. His abdomen was tender in the epigastric region. His labs revealed a white blood cell count of 14 x 109/L, lipase ampersand:003E 3,000 U/L, Bilirubin 40 umol/ L, AST 613 U/L, ALT 527 U/L, GGT 394 U/L, ALP 94 U/L, Creatinine 159 mmol/L. CT abdomen/pelvis revealed cholelithiasis without choledocholithiasis or biliary dilation. The pancreas was inflammed with necrosis throughout. There were two peripancreatic fluid collections (60mm x 41mm, and 148mm x 89mm). He was diagnosed with acute necrotizing pancreatitis thought secondary to gallstones. He was fluid resuscitated, started on antibiotics and unfractionated heparin (UFH) for deep vein thrombosis (DVT) prophylaxis. His oral intake remained low. Imaging on day 30 showed a large walled off necrotic collection (25cm x15cm). Vascular strucutres were patent. On day 36 he underwent endoscopic ultrasound guided drainage via lumen-apposing metal stent (LAMS). On day 43 he developed new tachycardia. CT chest revealed bilateral pulmonary emboli (Image 1). Doppler ultrasound revealed bilateral occlusive thrombus in the calf veins. He was treated with therapeutic UFH. Literature review: We identified 10 case reports describing AP complicated by PE. The age amonst reports was variable (21 to 68). 4 cases reported additional thrombosis outside of the pulmonary vasculature. No cases which described splanchnic venous thrombosis prior. 3 cases reported pancreatic necrosis. The use of DVT prophylaxis was not reported. There is one case of PE 2 days after LAMS insertion in a patient with known thromboembolic disease. Conclusions PE is a rare complication of AP. Novel to this case was the recent deployment of a LAMS, the significance of which is unknown to date. Improved documentation of variables in future reports is needed to further characterize this event. Image 1: Acute Pulmonary Embolism. Funding Agencies None

Metagenomic next-generation sequencing, instead of procalcitonin, could guide antibiotic usage in patients with febrile acute necrotizing pancreatitis: a multicenter, prospective cohort study.

The effectiveness of procalcitonin-based algorithms in guiding antibiotic usage for febrile acute necrotizing pancreatitis (ANP) remains controversial. Metagenomic next-generation sequencing (mNGS) has been applied to diagnose infectious diseases. We aimed to evaluate the effectiveness of blood mNGS in guiding antibiotic stewardship for febrile ANP. The prospective multicenter clinical trial was conducted at seven hospitals in China. Blood samples were collected during fever (T ≥38.5°C) from ANP patients. The effectiveness of blood mNGS, procalcitonin, and blood culture in diagnosing pancreatic infection was evaluated and compared. Additionally, the real-world utilization of antibiotics and the potential mNGS-guided antimicrobial strategy in febrile ANP were also analyzed. From May 2023 to October 2023, a total of 78 patients with febrile ANP were enrolled and 30 patients (38.5%) were confirmed infected pancreatic necrosis (IPN). Compared with procalcitonin and blood culture, mNGS showed a significantly higher sensitivity rate (86.7% vs. 56.7% vs. 26.7%, P<0.001). Moreover, mNGS outperformed procalcitonin (89.5% vs. 61.4%, P<0.01) and blood culture (89.5% vs. 69.0%, P<0.01) in terms of negative predictive value. Blood mNGS exhibited the highest accuracy (85.7%) in diagnosing IPN and sterile pancreatic necrosis (SPN), significantly superior to both procalcitonin (65.7%) and blood culture (61.4%). In the multivariate analysis, positive blood mNGS (OR=60.2, P<0.001) and lower fibrinogen level (OR=2.0, P<0.05) were identified as independent predictors associated with IPN, whereas procalcitonin was not associated with IPN, but with increased mortality (OR=11.7, P=0.006). Overall, the rate of correct use of antibiotics in the cohort was only 18.6% (13/70) and would be improved to 81.4% (57/70) if adjusted according to the mNGS results. Blood mNGS represents important progress in the early diagnosis of IPN, with particular importance in guiding antibiotic usage for patients with febrile ANP.

ANALYSIS OF THE STRUCTURE OF LOCAL COMPLICATIONS TO ACUTE NECROTIC PANCREATITIS USING RADIATION DIAGNOSTICS METHODS

The use of multispiral computed tomography and ultrasound examination in pancreatic necrosis makes it possible to determine the shape, volume and localization, to distinguish four types of lesions. The aim of the study was to determine the incidence rate and the structure of local aseptic and purulent complications in acute necrotic pancreatitis using radiation diagnostics methods, to assess complications impact on the course and prognosis of the disease. Materials and methods. 63 patients with pancreatic necrosis who underwent treatment were examined during 2 years. The results of these examinations were analyzed. Two groups were identified: 1st – patients with infected pancreatic necrosis 29 (46%), 2nd – patients with sterile one 34 (54%). Ultrasound examination was performed on expert-class scanners, multispiral computed tomography with bolus tracking was performed on an Aguilion Prim device manufactured by Toshiba. Statistical processing of the results was performed in the Microsoft Excel 2017 database, the calculation of average values, standard distribution errors was made, the analysis of conjugate frequencies was given – the xi-squared test (c2) was used. Study results. Four types of infiltrative-necrotic lesions were identified: 21 cases (33.3%) of model-1 (central type); 13 cases (20.7%) of model-2 (left type); 9 cases (14.3%) of model-3 (right type); 20 cases (31.7%) of model-4 (mixed type). In group 1, severe pancreatic necrosis was significantly more often identified – in 17 out of 29 (58.6%) (c2 = 5.414; p = 0.020), mixed type (model-4) – 14 of 29 (48.3%) (c2 = 5.436; p = 0,020); in the 2nd group that of moderate severity was found more often – 21 out of 34 (61.6%) (c2 = 8.511; p = 0.004), mainly the central type (model-1) – 17 of 34 (50%) (c2 = 7.675; p = 0.006). There are no differences in the structure of local complications in group 2 depending on the severity of necrosis, in group 1, widespread parapancreatitis was more common in 22 out of 29 cases (75.9%) (p &lt; 0.001). Mortality in infected and sterile pancreatic necrosis did not significantly differ – 24.1% and 23.5%, the highest mortality was in the mixed type of lesion in both groups (model-4) was 9 out of 20 (c2 = 5.643; p = 0.018). Conclusions. Radiation examination methods give the opportunity to predict early the pancreatic necrosis course and outcome. The development of local complications and their structure depend on the volume of necrosis, the prevalence and type of localization of destructive and inflammatory changes in retroperitoneal space.

A Clinic-Radiomics Model for Predicting the Incidence of Persistent Organ Failure in Patients with Acute Necrotizing Pancreatitis.

Persistent organ failure (POF) is the leading cause of death in patients with acute necrotizing pancreatitis (ANP). Although several risk factors have been identified, there remains a lack of efficient instruments to accurately predict the incidence of POF in ANP. Retrospectively, the clinical and imaging data of 178 patients with ANP were collected from our database, and the patients were divided into training (n = 125) and validation (n = 53) cohorts. Through computed tomography image acquisition, the volume of interest segmentation, and feature extraction and selection, a pure radiomics model in terms of POF prediction was established. Then, a clinic-radiomics model integrating the pure radiomics model and clinical risk factors was constructed. Both primary and secondary endpoints were compared between the high- and low-risk groups stratified by the clinic-radiomics model. According to the 547 selected radiomics features, four models were derived from features. A clinic-radiomics model in the training and validation sets showed better predictive performance than pure radiomics and clinical models. The clinic-radiomics model was evaluated by the ratios of intervention and mechanical ventilation, intensive care unit (ICU) stays, and hospital stays. The results showed that the high-risk group had significantly higher intervention rates, ICU stays, and hospital stays than the low-risk group, with the confidence interval of 90% (p < 0.1 for all). This clinic-radiomics model is a useful instrument for clinicians to evaluate the incidence of POF, facilitating patients' and their families' understanding of the ANP prognosis.

Feasibility of using software-aided selection of virtual monoenergetic level for optimal image quality of acute necrotising pancreatitis based on dual-energy computed tomography: a preliminary study

ObjectiveThis study aimed to assess the feasibility of software-aided selection of monoenergetic level for acute necrotising pancreatitis (ANP) depiction compared to other automatic image series generated using dual-energy computed tomography (CT).MethodsThe contrast-enhanced dual-source dual-energy CT images in the portal venous phase of 48 patients with ANP were retrospectively analysed. Contrast-to-noise ratio (CNR) of pancreatic parenchyma-to-necrosis, signal-to-noise ratio (SNR) of the pancreas, image noise, and score of subjective diagnosis were measured, calculated, and compared among the CT images of 100 kV, Sn140 kV, weighted-average 120 kV, and optimal single-energy level for CNR.ResultsCNR of pancreatic parenchyma-to-necrosis in the images of 100 kV, Sn140 kV, weighted-average 120 kV, and the optimal single-energy level for CNR was 5.18 ± 2.39, 3.13 ± 1.35, 5.69 ± 2.35, and 9.99 ± 5.86, respectively; SNR of the pancreas in each group was 6.31 ± 2.77, 4.27 ± 1.56, 7.21 ± 2.69, and 11.83 ± 6.30, respectively; image noise in each group was 18.78 ± 5.20, 17.79 ± 4.63, 13.28 ± 3.13, and 9.31 ± 2.96, respectively; and score of subjective diagnosis in each group was 3.56 ± 0.50, 3.00 ± 0.55, 3.48 ± 0.55, and 3.88 ± 0.33, respectively. The four measurements of the optimal single-energy level for CNR images were significantly different from those of images in the other three groups (P < 0.05). CNR of pancreatic parenchyma-to-necrosis, SNR of the pancreas, and score of subjective diagnosis in the images of the optimal single-energy level for CNR were significantly higher, while the image noise was lower than those in the other three groups (all P = 0.000).ConclusionOptimal single-energy level imaging for CNR of dual-source CT could improve quality of CT images in patients with ANP, enhancing the display of necrosis in the pancreas.

Fatal case of acute necrotic pancreatitis secondary to chronic abuse of acetaminophen: a case report

Acetaminophen is a widely used analgesic and antipyretic. It is also known to cause hepatotoxicity and is rarely associated with acute pancreatitis due to overdose. We report the case of a 55-year-old man with no known comorbidities, who presented with severe abdominal pain and vomiting. His medication history revealed chronic abuse of a fixed-dose combination containing 37.5 mg of tramadol hydrochloride and 325 mg acetaminophen 3-6 tablets per day for over 20 years for general body pain without a specific diagnosis. He was diagnosed with acetaminophen-induced acute necrotic pancreatitis after ruling out gallstones and other factors such as alcohol consumption, and family history. Although he got discharged against medical advice, follow-up revealed that he had succumbed to his illness within 15 days. This was a fatal case of acetaminophen-induced pancreatitis due to chronic abuse for over 20 years at a dose of less than 2 g/day. This case highlights the need for periodic monitoring of patients taking acetaminophen at doses within the recommended daily dose.

Colonic mucin-2 attenuates acute necrotizing pancreatitis in rats by modulating intestinal homeostasis.

Mucin-2 (MUC2) secreted by goblet cells participates in the intestinal barrier, but its mechanism in acute necrotizing pancreatitis (ANP) remains unclear. In acute pancreatitis (AP) patients, the functions of goblet cells (MUC2, FCGBP, CLCA1, and TFF3) decreased, and MUC2 was negatively correlated with AP severity. ANP rats treated with pilocarpine (PILO) (PILO+ANP rats) to deplete MUC2 showed more serious pancreatic and colonic injuries, goblet cell dysfunction, gut dysbiosis, and bacterial translocation than those of ANP rats. GC-MS analysis of feces showed that PILO+ANP rats had lower levels of butyric acid, isobutyric acid, isovaleric acid, and hexanoic acid than those of ANP rats. The expression of MUC2 was associated with colonic injury and gut dysbiosis. All these phenomena could be relieved, and goblet cell functions were also partially reversed by MUC2 supplementation in ANP rats. TNF-α-treated colonoids had exacerbated goblet cell dysfunction. MUC2 expression was negatively correlated with the levels of pro-inflammatory cytokines (IL-1β and IL-6) (p < .05) and positively related to the expression of tight junction proteins (Claudin 1, Occludin, and ZO1) (p < .05). Downregulating MUC2 by siRNA increased the levels of the pro-inflammatory cytokines in colonoids. MUC2 might maintain intestinal homeostasis to alleviate ANP.

Early vs. late percutaneous catheter drainage of acute necrotic collections in patients with necrotizing pancreatitis.

It is recommended to drain the pancreatic fluid collections later in the course of the acute necrotizing pancreatitis (ANP). However, earlier drainage may be indicated. We compared early (≤ 2weeks) vs. late (3rd to 4th week) percutaneous catheter drainage (PCD) of acute necrotic collections (ANC). This retrospective study comprised ANP patients who underwent PCD of ANC. The diagnosis of ANP was based on revised Atlanta classification criteria and computed tomography performed between 5 and 7days of illness. Patients were divided into two groups [1st 2 weeks (group I) and 3rd-4th weeks (group II)] based on the interval between the onset of pain and insertion of catheter. The technical success, clinical success, complications, and clinical outcomes were compared between the two groups. One hundred forty-eight patients (74 in each group) were evaluated. The procedures were technically successful in all patients. The clinical success rate was 67.6% in group I vs. 77% in group II (p = 0.069). The incidence of complications was significantly higher in group I (n = 12, 16%) than group II (n = 4, 5.4%) (p = 0.034). These included 15 minor (11 in group I and 4 in group II) and one major complication (group I). Of the clinical outcomes, the need for surgery was significantly higher in group I than in group II (13 patients vs. 5 patients, p = 0.031). Early PCD is as technically successful as late PCD in the management of ANC. However, early PCD is associated with higher surgical rate and higher incidence of complications.

Early systemic anticoagulation reduces hospital readmission in acute necrotizing pancreatitis patients: A retrospective cohort study

BackgroundEarly systemic anticoagulation (SAC) is a common practice in acute necrotizing pancreatitis (ANP), and its impact on in-hospital clinical outcomes had been assessed. However, whether it affects long-term outcomes is unknown. This study aimed to evaluate the effect of SAC on 90-day readmission and other long-term outcomes in ANP patients. MethodsDuring January 2013 and December 2018, ANP patients admitted within 7 days from the onset of abdominal pain were screened. The primary outcome was 90-day readmission after discharge. Cox proportional-hazards regression model and mediation analysis were used to define the relationship between early SAC and 90-day readmission. ResultsA total of 241 ANP patients were enrolled, of whom 143 received early SAC during their hospitalization and 98 did not. Patients who received early SAC experienced a lower incidence of splanchnic venous thrombosis (SVT) [risk ratio (RR) = 0.40, 95% CI: 0.26-0.60, P < 0.01] and lower 90-day readmission with an RR of 0.61 (95% CI: 0.41-0.91, P = 0.02) than those who did not. For the quality of life, patients who received early SAC had a significantly higher score in the subscale of vitality (P = 0.03) while the other subscales were all comparable between the two groups. Multivariable Cox regression model showed that early SAC was an independent protective factor for 90-day readmission after adjusting for potential confounders with a hazard ratio of 0.57 (95% CI: 0.34-0.96, P = 0.04). Mediation analysis showed that SVT mediated 37.0% of the early SAC-90-day readmission causality. ConclusionsThe application of early SAC may reduce the risk of 90-day readmission in the survivors of ANP patients, and reduced SVT incidence might be the primary contributor.

Acute Pancreatitis as a Rare and Unusual Manifestation of COVID-19 in a Child with Acute Lymphoblastic Leukemia

Introduction: The coronavirus disease 2019 (COVID-19) mainly causes pulmonary disease. However, extrapulmonary manifestations, which affect the gastrointestinal tract and hepatobiliary system, have been reported. Case Presentation: Here we reported a 4-year-old boy with acute lymphoblastic leukemia and abdominal pain who had acute necrotic pancreatitis secondary to COVID-19. Conclusions: According to the COVID-19 epidemic, if drug-induced pancreatitis is ruled out, viral causes, especially COVID-19, should be considered.

Association between pretreatment lymphocyte count and efficacy of immune-enhancing therapy in acute necrotising pancreatitis: a post-hoc analysis of the multicentre, randomised, placebo-controlled TRACE trial

Immune-enhancing thymosin alpha 1 (Tα1) therapy may reduce infected pancreatic necrosis (IPN) in acute necrotising pancreatitis (ANP). However, the efficacy might be impacted by lymphocyte count due to the pharmacological action of Tα1. In this post-hoc analysis, we tested the hypothesis that pre-treatment absolute lymphocyte count (ALC) determines whether patients with ANP benefit from Tα1 therapy. A post-hoc analysis of data from a multicentre, double-blind, randomised, placebo-controlled trial testing the efficacy of Tα1 therapy in patients with predicted severe ANP was performed. Patients from 16 hospitals of China were randomised to receive a subcutaneous injection of Tα1 1.6mg every 12h for the frst 7 days and 1.6mg once a day for the following 7 days or a matching placebo during the same period. Patients who discontinued the Tα1 regimen prematurely were excluded. Three subgroup analyses were conducted using the baseline ALC (at randomisation), and the group allocation was maintained as intention-to-treat. The primary outcome was the incidence of IPN 90 days after randomisation. The fitted logistic regression model was applied to identify the range of baseline ALC where Tα1 therapy could exert a maximum effect. The original trial is registered with ClinicalTrials.gov, NCT02473406. Between March 18, 2017, and December 10, 2020, a total of 508 patients were randomised in the original trial, and 502 were involved in this analysis, with 248 in the Tα1 group and 254 in the placebo group. Across the three subgroups, there was a uniform trend toward more significant treatment effects in patients with higher baseline ALC. Within the subgroup of patients with baseline ALC≥0.8×10ˆ9/L (n=290), the Tα1 therapy significantly reduced the risk of IPN (covariate adjusted risk difference,-0.12; 95% CI,-0.21,-0.02; p=0.015). Patients with baseline ALC between 0.79 and 2.00×10ˆ9/L benefited most from the Tα1 therapy in reducing IPN (n=263). This post-hoc analysis found that the efficacy of immune-enhancing Tα1 therapy on the incidence of IPN may be associated with pretreatment lymphocyte count in patients with acute necrotising pancreatitis. National Natural Science Foundation of China.

Pancreatic Necrosis Infection as a Determinant of Multiple Organ Failure and Mortality in Acute Pancreatitis.

Several recommendations and data on the treatment of acute necrotizing pancreatitis (ANP) are conflicting and different surgical approaches continue to exist. We conducted a study on 148 patients with ANP, who were divided into two groups: the main group (n = 95) when the tactics of the step-up approach were applied with the principles of the concept of Enhanced Recovery After Surgery (ERAS) in order to determine this approach on effectiveness in reducing complications and 30-day mortality (2017-2022); the comparison group (n = 53) when the same tactic of the treatment was used without ERAS principles (2015-2016). Treatment time for the main group in the intensive care unit was minimized (p ≤ 0.004); it has been shown to reduce the frequency of complications in these patients (p < 0.001) requiring conservative or surgical treatment without general anaesthesia (Clavien-Dindo I-IIIa); no statistically significant differences were observed for the total incidence of Clavien-Dindo IIIb-IVb complications (p > 0.05); the median duration of treatment for patients in the primary group was 23 days, and in the reference group-34 days (p ≤ 0.003). Pancreatic infections have been observed in 92 (62.2%) patients and gram-negative bacteria predominated in the overall pathogen structure with 222 (70.7%) strains. The only evidence of multiple organ failure before (AUC = 0.814) and after surgery (AUC = 0.931) was found to be predictive of mortality. Antibiotic sensitivity of all isolated bacteria better understood local epidemiology and identified the most effective antibiotics when treating patients.

Involvement of transverse mesocolon is associated with development of colonic fistula in patients with acute necrotizing pancreatitis

BackgroundInvolvement of transverse mesocolon (TM) during acute necrotizing pancreatitis(ANP) indicates that inflammation has spread from retroperitoneal space to peritoneum. Nevertheless, the impact of TM involvement, as confirmed by contrast-enhanced computed tomography (CECT), on local complications and clinical outcomes was poorly investigated. PurposeThis study aimed to explore the association between CECT-diagnosed TM involvement and the development of colonic fistula in a cohort of ANP patients. MethodsThis is a single-center, retrospective cohort study involving ANP patients admitted from January 2020 to December 2020. TM involvement was diagnosed by two experienced radiologists. The study subjects were enrolled consecutively and divided into two groups: TM involvement and non-TM involvement. The primary outcome was colonic fistula during the index admission. Clinical outcomes were compared between the two groups, and the association between the TM involvement and the development of colonic fistula was assessed using multivariable analysis to adjust for baseline unbalances. ResultsA total of 180 patients with ANP were enrolled, and 86 (47.8%) patients had TM involvement. The incidence of the colonic fistula is significantly higher in patients with TM involvement (16.3% vs. 5.3%;p = 0.017). Moreover, the length of hospital stay was 24(13,68) days in patients with TM involvement and 15(7,31) days in those not (p = 0.001). Analysis of multivariable logistic regression revealed that TM involvement is an independent risk factor for the development of colonic fistula (odds ratio: 10.253, 95% CI: 2.206–47.650, p = 0.003). ConclusionTM involvement in ANP patients is associated with development of colonic fistula in ANP patients.