CT Severity Index Research Articles

Correlation of modified CT Severity Index with Complications of Acute Pancreatitis

Correlation of modified CT Severity Index with Complications of Acute Pancreatitis

Site and size of extrapancreatic necrosis are associated with clinical outcomes in patients with acute necrotizing pancreatitis

BackgroundThe site and size of extrapancreatic necrosis (EPN) as assessed on computed tomography may influence the severity of acute necrotizing pancreatitis (ANP). The objective of the study was to evaluate the impact of site and size of EPN on the clinical outcomes in patients with acute necrotizing pancreatitis (ANP). Method and materialsThis retrospective study comprised of consecutive patients with ANP who were admitted between January 2017 and March 2019. Patients in whom the initial contrast enhanced CT showed EPN were eligible for inclusion. The site, volume and maximum dimension of EPN were recorded. The severity of AP and modified CT severity index (MCTSI) was calculated. Clinical outcomes were recorded. ResultsA total of 119 patients (mean age, 37.56 years, 91 males) were included. There was a significant association between the location of EPN and the outcome parameters. The left posterior pararenal collections were significantly associated with mortality (P = 0.041), left paracolic gutter collections with the length of hospitalisation (LOH) (P = 0.014), and right paracolic gutter and mesenteric collections with the intensive care unit (ICU) stay (P = 0.024, and P = 0.021, respectively). There was a significant correlation between the volume and the maximum dimension of collection with LOH and ICU stay. The area under the receiver operating characteristic curve for volume, maximum dimension and MCTSI for predicting death was 0.724 (95% CI, 0.612–0.837), 0.644 (95% CI, 0.516–0.772) and 0.574 (95% CI, 0.452–0.696), respectively. ConclusionThe site and size of EPN provide reliable and objective information for assessing clinical outcomes in patients with ANP.

The efficacy of low molecular weight heparin in severe acute pancreatitis: A systematic review and meta-analysis of randomized controlled trials.

The effects of low molecular weight heparin (LMWH) on severe acute pancreatitis (SAP) have been controversial. We aimed to evaluate the efficacy of LMWH on prognosis of SAP by systematic review and meta-analysis. We searched relevant studies published up to March 2019 in five databases (MEDLINE/PubMed, EMBASE, the Cochrane Central Register of Controlled Trials in Cochrane Library, China National Knowledge Infrastructure, and the Chinese Journal of Science and Technology of VIP database). Sixteen randomized controlled trials with 1625 patients were included in the final analysis. Most studies were from China. In analysis of laboratory parameters and clinical scores, SAP patients receiving LMWH treatment had lower white blood cell counts, C-reactive protein level, Acute Physiology and Chronic Health Evaluation II score, and computed tomography severity index. In clinical outcomes, SAP patients who received LMWH treatment had shorter hospital stay (pooled mean difference [95% confidence interval; CI] -8.79 [-11.18, -6.40], P < .01), lower mortality (pooled risk ratio [RR] [95% CI] 0.33 [0.24-0.44], P < .01), lower incidences of multiple organ failure (pooled RR [95% CI] 0.34 [0.23-0.52], P < .01), pancreatic pseudocyst (pooled RR [95% CI] 0.49 [0.27-0.90], P = .02), and operation rate (pooled RR [95% CI] 0.39 [0.31-0.50], P < .01). LMWH could improve the prognosis of SAP, and has a potential role in reducing hospital stay, mortality, incidences of multiple organ failure, pancreatic pseudocyst, and operation rate.

353 An Open-Label, Dose-Response Study of CM4620-Injectable Emulsion in Emergency Department Patients With Acute Pancreatitis

Hyperactivation of Calcium Release-Activated Calcium (CRAC) channels results in excessive Ca2+ influx in acinar cells and plays a pivotal role in cellular injury and the progression of acute pancreatitis. Our purpose was to evaluate the efficacy of CM4620-IE, a potent selective CRAC channel inhibitor, to improve outcomes in ED patients with acute pancreatitis. This was a 2 phase, open-label, multicenter, placebo controlled dose-response pilot study enrolling patients with acute pancreatitis (AP), who met SIRS criteria, and who had a room air SpO2 <96% (NCT03401190). Patients were randomized in a 3:1 fashion to CM4620-IE or placebo, in all phases. In phase 1, patients received 1.0 mg/kg on day 1 and 1.4 mg/kg on Days 2-4. In phase 2, females had the same dose of CM4620-IE as in the 1st phase, and males received 2.08 mg/kg of CM4620-IE on Days 1-2, and 1.6 mg/kg on Days 3-4. Patients were discharged after meeting local criteria, potentially before completion of study drug. All patients had pancreatic CT imaging before randomization and again at the earliest of days 5-7 or discharge. CTs, read by a central reader blinded to therapy, were graded as severe AP (SAP), moderately SAP (MSAP), or mild AP (MAP) using the CT severity index (CTSI) scoring system. All patients had daily dietary assessments, and tolerating a solid diet was defined as eating >50% of a solid meal. Of 21 patients, 14 received CM4620-IE and 7 placebo. Five females and 3 males received low dose and 6 males received the high dose CM4620-IE. In both phases, all CM4620-IE patients received a median of 3 doses. The median age, baseline SpO2, number of patients with >2 SIRS criteria, and percent of patients with MSAP or SAP on the initial CT were comparable between CM4620-IE and placebo. The results are presented in Table 1. No serious adverse events were reported as being drug-related. CM4620-IE was well tolerated, was not associated with an increase in serious adverse events and had multiple efficacy signals that warrant further clinical development and a larger Phase 2b/3 study.Table 1Main ResultsCM4620-IE, N=14SOC, N=7Age, median (IQR)50.5 (26, 66)54 (40, 72)Screening SpO2, median (IQR)94% (93, 95)94% (93, 95)Screening HR, median (IQR)105 (100, 109)105 (102, 116)Screening SBP mmHg, median (IQR)156 (143, 172)129 (124, 145)Baseline Median Pain Score (0-10) (IQR)8 (5, 9)8 (6, 8)Patients with ≥3 SIRS criteria at screening, n (%, 95% CI)4 (28.6%, 11.7-54.6%)2 (28.6%, 8.2-64.1%)Baseline moderate or severe pancreatitis by CTSI score, n (%, 95% CI)9 (64.3%, 38.8-83.7%)4 (57.1%, 25.0-84.2%)Baseline Pain Score (0-10) (IQR)8 (5, 9)8 (6, 8)Tolerating solid diet at 72 hours, n (%, 95% CI)8 (57.1%, 32.6-78.6%)1 (14.3%, 2.6-51.3%)Tolerating solid diet at discharge, n (%, 95% CI)12 (85.7%, 36.5-75.5%)3 (42.9%, 15.8-75.0%)Baseline moderate or severe pancreatitis converting to mild, n (%, 95% CI)5 (37.5%, 16.3-61.2%)0 (0%, 0.0-35.4%)SIRS persisting ≥48 hours, n (%, 95% CI)5 (35.7%, 16.3-61.2%)5 (71.4%, 35.9-91.8%)Development of de-novo acute kidney injury, n (%, 95% CI)1 (8.3%, 1.3-31.5%)1 (20%, 2.6-51.3%)Length of stay for all patients, median days (IQR)3.7 (2.5, 8.4)6.0 (2.5, 7.3)Length of stay for moderate or severe pancreatitis, median days (IQR)4.3 (1.9, 12.3)7.3 (6.6, 18.7) Open table in a new tab

DIFFERENT SCORING SYSTEMS IN ACUTE ALCOHOLIC PANCREATITIS: WHICH ONE TO FOLLOW? AN ONGOING DILEMA.

Acute pancreatitis is a common disorder in medical practice. In recent times, management has changed drastically with majority of decisions like intravenous antibiotics, negative suction with Ryle's tube and surgical interventions like necrosectomy etc based on severity of the disease. There are different scores in use to assess severity of disease but the relative efficacy has remained a debatable subject. The present study was thus done to investigate the predictive accuracy of different scoring systems in acute pancreatitis. Fifty patients of acute pancreatitis admitted in medicine ward of Pt. B.D. Sharma PGIMS, Rohtak, India, were taken for study after fulfilling eligibility criteria. These patients were investigated at admission and followed up prospectively. The severity of pancreatitis was classified for each of these patients as per Revised Atlanta System of Classification. Commonly used scoring systems pertaining to acute pancreatitis, viz, BISAP, Ranson, APACHE II and modified computed tomography severity index (CTSI) were calculated. Subsequently these scores were then correlated with severity, presence of organ failure, occurrence of local complications and final outcome of the patients. Out of 50 patients, etiology was chronic alcohol intake in all but one with idiopathic pancreatitis. The mean age of the study population was 42.06±13.27 years. 32% of these patients had pancreatic necrosis, 40% had peripancreatic collections. 56% of them had mild acute pancreatitis, 24% had moderately severe acute pancreatitis, while 20% had severe acute pancreatitis. APACHE II had the highest accuracy in predicting severity, organ failure and fatal outcomes. As far as these parameters were concerned, the negative predictive values of BISAP score were also considerable. Modified CTSI score was accurate in predicting local complications but had limited accuracy in other predictions. APACHE II emerged as most reliable scoring system followed by BISAP and Ranson in management of the patients with acute pancreatitis. But in constraints of time and resources, even BISAP score with its significant negative predictive values served as a valuable tool for assessing and managing these patients.

A study of interventions and their outcome in the management of acute pancreatitis

Background: Acute pancreatitis is the most terrible of all the calamities that occur in connection with the abdominal viscera. The suddenness of its onset, the illimitable agony which accompanies it, and the mortality attendant upon it, all render it the most formidable of catastrophes. Aim of the study is to evaluate the treatment outcome in acute pancreatitis.Methods: All the patients who underwent surgery for chronic pancreatitis were included in the study. initial APACHE II score at admission and CT severity index was evaluated.Results: Edematous pancreatitis accounts for 80–90% of acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing pancreatitis occupies 10–20% of acute pancreatitis and the mortality rate is reported to be 14-25%. Alcohol (45.8%) was the most common causes of acute severe pancreatitis in this study. Males were predominately affected (Male: Female = 29:5). Complication rate or morbidity is 50%. The initial APACHE II score at admission and CT severity index in the first scan were high in patients who underwent necrosectomy and the patients who died. The overall mortality in this study was 30.6%.Conclusions: In conclusion, one reason attributed to high mortality was due to the subgroup of patients who underwent PCD alone and failed to show any change in the recovery nor deterioration and lead to gross nutritional depletion and death, secondly those patients who underwent step up approach and ultimately needed surgery have more aggressive disease evidenced by high APACHE II score, CT severity index and % of necrosis.

Advantages of Modified Computed Tomography Severity Index of Acute Pancreatitis Over Other Scoring System

Pancreatitis is one of most complex and clinically challenging of all abdominal disorders. USG and abdominal Computed Tomography (CT) are the most commonly used diagnostic imaging modalities for the evaluation of pancreas. Computed Tomography (CT) is highly accurate and sensitive than USG in both diagnosing as well as demonstrating the extent. Early assessment of the cause and severity of acute pancreatitis is of utmost importance for prompt treatment and close monitoring of patient with severe disease. CT is the imaging method of choice for assessing the extent of acute pancreatitis and for evaluating complications. CT severity index is used to assess prognostic correlation and clinical outcome of acute pancreatitis. Modified CT severity index makes the score easier to calculate and reduces the inter-observer variation.&#x0D; KYAMC Journal Vol. 10, No.-2, July 2019, Page 110-113

Role of extrapancreatic necrosis volume in determining early prognosis in patients with acute pancreatitis.

This study aims to evaluate the capacity of the clinical and radiological findings and the extrapancreatic necrotic tissue volume in early (2-6days) computerized tomography (CT) images of patients diagnosed with AP to predict reliably the temporary or permanent organ failure and other local or systemic complications due to pancreatitis. Adult patients who were diagnosed with AP based on Revised Atlanta classification and underwent abdomen CT scans between May 2015 and May 2018 were examined retrospectively. Extrapancreatic necrosis volume was compared to various clinical parameters that indicate the prognosis of AP such as C-reactive protein (CRP) at 48-72th h, organ failure, infection, requirement for percutaneous or surgical intervention, length of hospital stay, and mortality, and to various imaging-based scoring systems such as the computerized tomography severity index (CTSI) and the modified CTSI (mCTSI). The receiver operating characteristic (ROC) curve was used to estimate the optimal threshold for predicting clinical prognosis. Extrapancreatic necrosis volume had moderate positive correlation with length of hospital stay (p = 0.0001) and CRP (at 48-72thh) (p = 0.0001) and strong positive correlation with CTSI (p = 0.0001), mCTSI (p = 0.0001), and white blood cell count (p = 0.0001). Extrapancreatic necrosis volume was found to be particularly better in predicting organ failure and infection compared to the imaging-based scoring systems (Balthazar, CTSI, and mCTSI) and the laboratory-based scoring systems (CRP at 48-72thh).

Clinical Characteristics and Risk Factors for Sinistral Portal Hypertension Associated with Moderate and Severe Acute Pancreatitis: A Seven-Year Single-Center Retrospective Study.

BackgroundThis study aimed to assess the prevalence, clinical characteristics, and risk factors for sinistral portal hypertension in patients with moderate or severe acute pancreatitis.Material/MethodsA retrospective study included 825 patients with moderate or severe acute pancreatitis. Clinical and demographic data, the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Ranson scores for severity of acute pancreatitis, and the computed tomography (CT) severity index (CTSI) were evaluated. The formation of collateral vessels, bleeding, splenomegaly, hypersplenism during hospitalization or follow-up, and early anticoagulation and the occurrence of sinistral portal hypertension were evaluated.ResultsOf the 825 patients with moderate or severe acute pancreatitis, 103 patients (12.5%) developed sinistral portal hypertension. The median time to diagnosis was 8 months, and the median patient age was 39 years. The most common causes of pancreatitis were biliary (46.3%), hypertriglyceridemia (31.5%), alcohol (14.9%), and others (7.3%). Independent risk factors for sinistral portal hypertension were male gender (OR, 4.666; 95% CI, 2.54–8.572; P<0.001), recurrent acute pancreatitis (OR, 9.556; 95% CI, 5.218–17.5; P<0.001), hypertriglyceridemia (OR, 2.056; 95% CI, 1.184–3.57; P=0.001), glucose >10 mmol/L (OR, 6.965; 95% CI, 4.027–12.045; P<0.001), smoking (OR, 6.32; 95% CI, 3.544–11.269; P<0.001), and infection of walled-off necrosis (OR=1.637; 95% CI, 1.061–2.524; P=0.015). Anticoagulation during hospitalization was not significantly associated with sinistral portal hypertension.ConclusionsHypertriglyceridemia, hyperglycemia, infection of walled-off necrosis, recurrent acute pancreatitis, and smoking were risk factors for sinistral portal hypertension, and early anticoagulation did not prevent the occurrence.

Subsets associated with developing acute pancreatitis in patients with severe hypertriglyceridemia and the severity of pancreatitis

Background and objectivesHypertriglyceridemia (HTG) is a rare but well-recognized cause for acute pancreatitis (AP). This study aimed to determine subsets related to development of AP in patients with severe HTG and the severity of HTG-induced AP (HTG-AP). MethodsPatients who had severe HTG (serum triglyceride level >1,000 mg/dL) more than once between Jan. 2010 and Dec. 2017 in a single institute were evaluated retrospectively. Patients were divided into two groups, with AP or without AP, and were compared. HTG-APs in patients with severe HTG were compared to APs due to other causes during the same period. ResultsSixty-three patients (19.3%) presented with AP of a total 326 patients with severe HTG. The AP group displayed younger age, more alcohol consumption and diabetes mellitus, and higher initial/maximum serum levels of triglyceride, glucose, HbA1c, total cholesterol, and calculated non-high-density lipoprotein cholesterol (p < 0.05). HTG-APs were clinically more severe compared with 277 APs due to other causes in terms of CRP (p < 0.001), CT severity index (p = 0.002), revised Atlanta classification (p < 0.001), and hospital stay (p = 0.011). In logistic regression analysis, maximum serum triglyceride level (OR 2.706, p = 0.015), alcohol consumption amount (OR 5.292, p < 0.001), and age (OR 0.358, p = 0.017) were independently associated with development of AP in patients with severe HTG. ConclusionsDevelopment of AP in patient with severe HTG was independently associated with younger age, higher serum TG level, and more alcohol consumption. HTG-APs are clinically more severe than APs due to other causes.

CT appearance of acute pancreatitis using multiphase Multidetector Computed Tomography and correlation between CT Severity Index and clinical outcomes

CT appearance of acute pancreatitis using multiphase Multidetector Computed Tomography and correlation between CT Severity Index and clinical outcomes

Predictors of outcome of percutaneous catheter drainage in patients with acute pancreatitis having acute fluid collection and development of a predictive model

BackgroundPercutaneous catheter drainage (PCD) is effective initial strategy in the step-up approach of management of acute pancreatitis (AP). The objective of this study was to identify factors associated with outcomes after PCD and develop a predictive model. Method and materialsIn a prospective observational study between July 2016 and Nov 2017, 101 consecutive AP patients were treated using a “step-up approach” in which PCD was used as the first step. We evaluated the association between success of PCD (survival without necrosectomy) and baseline parameters viz. etiology, demography, severity scores, C-reactive protein (CRP), and intra-abdominal pressure (IAP), morphologic characteristics on computed tomography (CT) [percentage of necrosis, CT severity index (CTSI), characteristics of collection prior to PCD (volume, site and solid component of the collection), PCD parameters (initial size, maximum size, number and duration of drainage) and factors after PCD insertion (fall in IAP, reduction in volume of collection). ResultsAmong 101 patients, 51 required PCD. The success rate of PCD was 66.66% (34/51). Four patients required additional surgical necrosectomy after PCD. Overall mortality was 29.4% (15/51). Multivariate analysis showed percentage of volume reduction of fluid collection (p = 0.016) and organ failure (OF) resolution (p = 0.023) after one week of PCD to be independent predictors of success of PCD. A predictive model based on these two factors resulted in area under curve (AUROC) of 0.915. Nomogram was developed with these two factors to predict the probability of success of PCD. ConclusionOrgan failure resolution and reduction in volume of collection after one week of PCD are significant predictors of successful PCD outcomes in patients with fluid collection following AP

Effect of continuous renal replacement therapy during percutaneous drainage in severe acute pancreatitis patients: a retrospective cohort study

To evaluate the clinical efficacy and safety of continuous renal replacement therapy (CRRT) in patients with severe acute pancreatitis (SAP) receiving percutaneous drainage (PCD). Clinical data of SAP patients receiving PCD admitted to department of hepatobiliary surgery of the First Affiliated Hospital of Xi'an Jiaotong University from November 11th 2015 to May 13th 2018 were retrospectively analyzed. The patients were divided into CRRT group and control group according to whether or not receiving CRRT. Demographic data, relevant variables before and after PCD, complication and outcome were all compared. A total of 75 patients were included in the study, 30 were treated with application of CRRT and 45 without CRRT. (1) There was no significant difference in gender, age, body mass index (BMI), medical history (smoking, drinking), complications (cardiovascular disease, chronic lung disease, diabetes, chronic renal insufficiency), etiology (gallstone, alcohol abuse, hyperlipidemia and others), or white blood cell count (WBC), C-reactive protein (CRP), serum procalcitonin (PCT), fluid resuscitation, mechanical ventilation, vasoactive agent or intra-abdominal pressure within 48 hours after admission between the two groups. However, acute physiology and chronic health evaluation II (APACHE II) score within 48 hours after admission of CRRT group was significantly higher than that of control group (18.3±4.5 vs. 12.8±6.2, P < 0.05). (2) There was no significant difference in WBC, PCT, APACHE II score or computed tomography severity index (CTSI) before PCD between the two groups. There was no significant difference in the position or times of PCD procedure between the two groups, but the time interval of PCD in the CRRT group was significantly longer than that in the control group (days: 19.4±5.4 vs. 12.8±2.2, P < 0.05). Meanwhile, there was no significant difference in drainage of fluid properties, incidence of abdominal bleeding, infection, gastrointestinal fistula, endoscopic removal of necrotic tissue, laparotomy for removal of necrotic tissue or the time from PCD to endoscopy or laparotomy between two groups. However, the length of intensive care unit (ICU) stay and the length of hospital stay in the CRRT group were significantly longer than those in the control group (days: 23.2±8.5 vs. 15.3±12.1, 51.2±21.2 vs. 31.2±14.0, both P < 0.01). (3) Kaplan-Meier survival analysis showed that there was no significant differences in 1-year or 3-year cumulative survival rates between the two groups (χ21 = 0.097, P1 = 0.755; χ22 = 0.013, P2 = 0.908). CRRT is safe and feasible in the treatment of SAP patients receiving PCD procedure. It does not increase the risk of bleeding and may delay the time interval of PCD intervention. However, it may prolong the length of ICU stay and the length of hospital stay. It should be worthy of much attention for clinicians.

CT-severity index can predict the severity of acute pancreatitis similar than other scoring systems

An investigation on the Consolidation by Atmospheric Pressure (CAPing) of a gas atomized commercial T15 tool steel powder is presented. The study was carried out over a range of temperature between 1150 and 1250 °C using loose powder encapsulated in Pyrex glass bottles. The densification mechanisms during CAPing process are subjected to several factors, such as sintering temperature and time, powder particle size and vacuum level. The results indicated that the densification of this powder can be enhanced by decreasing powder particle size and increasing the vacuum level, temperature and time of sintering. Glass penetration is a special characteristic of this process. At some conditions, the highly fluid glass may penetrate deeply throughout the powder aggregate and prevents it from densifying. This study has showed that during CAPing of T15 tool steel powder, there is a competition between the densification and the glass penetration rates. At high temperature (1250 °C) and high vacuum level (10−5tor), the pore closure rate is higher than glass penetration rate and this leads to full density of the material within only 1.5 h. However, at lower temperatures and vacuum conditions, the powder material needs much longer time to reach higher densities. Finally, it can be said that this process offers the possibility of closing the residual porosity and a good control of structural refinement, as well as a substantial production cost savings which could prove a crucial decision making parameter for industrial exploitation of the process.

Serum apolipoprotein B-to-apolipoprotein A1 ratio is independently associated with disease severity in patients with acute pancreatitis

Early identification of severe acute pancreatitis (SAP) is critical for clinical decision-making. The apolipoprotein B-to-apolipoprotein A1 ratio (ApoB/A1 ratio) reflects the balance between pro-inflammation and anti-inflammation in vivo. This study investigated the association between serum ApoB/A1 ratio at admission and acute pancreatitis (AP) severity. A total of 375 patients with first attack of AP were retrospectively recruited from January 2014 to December 2017. The severity of AP was assessed at admission based on the 2012 revised Atlanta Classification. Serum lipids levels were tested on the first 24 h of hospitalization, of which the correlations with clinical features or scoring systems were also measured. The ApoB/A1 ratio markedly increased across disease severity of AP. The ApoB/A1 ratio, expressed as both quartile and continuous variables, was significantly associated with a high risk of SAP, even after adjustment for other conventional SAP risk factors. The ApoB/A1 ratio positively correlated with the revised 2012 Atlanta Classification, Ranson score, Bedside Index for Severity in AP score, Modified Computed Tomography Severity Index score, and Acute Physiology and Chronic Health Evaluation II score for AP severity. The optimal cut-off value of ApoB/A1 ratio for detecting SAP was 0.88, with a sensitivity of 83.08% and a specificity of 69.03%. Serum ApoB/A1 ratio at admission is closely correlated with disease severity in patients with AP and can serve as a reliable indicator for SAP in clinical setting.

Intra peritoneal abdominal fat area measured from computed tomography is an independent factor of severe acute pancreatitis

The purpose of this study was to search for a possible relationship between acute pancreatitis (AP) severity and visceral fat (VF) surface on contrast-enhanced computed tomography (CECT). A total of 112 patients with AP who underwent CECT within 2 to 3 days after the beginning of AP were included. There were 68 mean and 44 women, with a mean age of 56.3±21.6 (SD) years (range: 19-98 years). AP was regarded as mild for patients with an hospital stay up to 5 days and severe for those with an hospital stay greater than 5 days. VF surface was measured on CECT at the level of L4-L5 and of the umbilicus. Association between AP severity and VF surface, computed tomography severity index (CTSI), modified CTSI (mCTSI) and other variables were searched for using uni- and multivariate analysis. At univariate analysis, the VF surface at the level of L4 was greater in patients with severe AP (129.3±68.6 [SD] cm2; range: 21.8-355.8 cm2) than in patients with mild AP (100.1±68.4 [SD] cm2; range:13.2-333 cm2) (P=0.006). Similarly, the VF surface at the umbilicus was greater in patients with severe AP (161.1±76.1 [SD] cm2; range: 31.3-376.7cm2) than in those with mild AP (128.4±74.3cm2; range: 12.8-323.1cm2) (P=0.024). CTSI and mCTSI were also associated to AP severity. At multivariate analysis, only VF surface either measured at the umbilical or at the L4-L5 level was associated with AP severity (P=0.017 and 0.006, respectively). VF surface at the level of L4-L5 on CECT is an independent factor of AP severity. VF surface at the level of L4-L5 on CECT is an independent factor of AP severity. These results are in line with recent data on the role of abdominal fat in the genesis of inflammatory response, which is associated with severe forms of AP.

Early Systemic Inflammatory Response Syndrome Duration Predicts Infected Pancreatic Necrosis

Background and PurposeSystemic inflammatory response syndrome (SIRS) was considered to play an important role in the progress of acute pancreatitis, but its specific relation with infected pancreatic necrosis remains largely unclear. We aimed to investigate the correlation between SIRS duration and infected pancreatic necrosis, and its application in prediction of infected pancreatic necrosis. MethodsA prospective observational cohort study of 2130 patients with acute pancreatitis from 2012 to 2017. The SIRS duration at the first week was registered daily, and demographic, radiology, and all clinical laboratory data were prospectively collected and retrospectively reviewed. ResultsA significant upward tendency of infected pancreatic necrosis incidence was observed with increased SIRS duration. In multivariate logistic regression, SIRS duration (odds ratio, 1.305; 95% CI, 1.161–1.468) was independently associated with infected pancreatic necrosis. ROC analysis demonstrated that the areas under curves of SIRS duration for predicting persistent multi-organ failure, pancreatic infection, and mortality were 0.97 (95% CI, 0.96–0.98), 0.92 (95% CI, 0.91–0.94), and 0.86 (95% CI, 0.83–0.90), respectively, which were comparable to, or even greater than, the area under curves of APACHE II and CT severity index scores. ConclusionsEarly SIRS duration was strongly associated with infected pancreatic necrosis and could serve as an easy bedside indicator to predict pancreatic infection.

Internal Drainage of Infected Pancreatic Necrosis: A Fail-Safe Alternative to Percutaneous Catheter Drainage

Necrosectomy and external drainage has been the traditional surgical treatment for infected pancreatic necrosis (IPN) following acute pancreatitis. It is a highly invasive and high risk procedure in an already compromised individual and demands multiple trips to the operating room for subsequent debridement. Recent evidence suggests that minimally invasive procedures, including surgical video-assisted retroperitoneal debridement and percutaneous catheter drainage (PCD) can often “take the heat out of the fire” and thereby delay or even avoid surgery, but these procedures sometimes fail and surgical intervention needs to be undertaken. In order to avoid multiple surgical procedures we decided to drain the IPN internally into the stomach. To ascertain the efficacy and safety of open necrosectomy and internal drainage into the stomach as a feasible alternative in patients with IPN. We conducted a prospective study of the results of open surgical necrosectomy and internal drainage performed on patients with IPN from March 2012 to February 2019. This was a record based qualitative study. The patients were initially managed in the intensive care unit (ICU) with goal-directed therapy and organ support where indicated. All patients with IPN requiring PCD or surgical intervention were included in this study. A total of 44 patients with acute necrotizing pancreatitis who underwent either PCD or surgical drainage were included in the study. Of the 44 patients, 16 (36.4%) were treated with open transgastric debridement and internal drainage into the stomach for IPN. The mean age of this subgroup of patients was 51.3 ± 11.1 years, the most common etiology of the pancreatitis was alcoholic, the mean acute physiology and chronic health (APACHE II) score of these patients was 15.9 ± 4.72, and the mean bedside index of severity in acute pancreatitis (BISAP) score was 4.92 ± 0.11. On contrast enhanced computed tomography (CECT) scan of the abdomen, 93.8% of the patients had >50% necrosis, with a mean CT severity index (CTSI) of 9.3 ± 0.7. The mean operating time was 137 ± 42.4 minutes, with a mean blood loss of 225.4 ± 50.5 ml. Two patients required reoperation because of persistence of necrosum and signs of collection on repeat CT, and there were two mortalities. None of the patients had any late complications related to the surgery and the procedure was successful in 91%. Internal drainage into the stomach in IPN is a feasible and relatively safe procedure when indicated. It is more effective in avoiding repeated surgical procedures when compared to external drainage.

Confocal laser endomicroscopy reveals alterations in duodenal permeability in patients with acute pancreatitis.

ObjectiveIntestinal permeability increases during the course of acute pancreatitis (AP). We assessed duodenal permeability alterations in patients with AP by confocal laser endomicroscopy (CLE).MethodsThirty patients with AP underwent CLE evaluation of the antral and duodenal mucosa. Images were graded based on the appearance of capillaries and the degree of fluorescein leakage.ResultsPatients with AP had increased duodenal mucosal permeability that could be detected by CLE. The mucosal permeability progressively increased in the gastric antrum, duodenal bulb, and descending duodenum. The CLE parameters in the antrum and duodenal bulb were not significantly different between patients with mild and severe AP. The CLE grades in the descending duodenum were higher in patients with severe than mild AP. The C-reactive protein level in AP was positively correlated with the permeability in the duodenal bulb and descending duodenum, while the computed tomography severity index score was positively correlated with the mucosal permeability in the duodenal bulb and descending duodenum.ConclusionCLE revealed increased duodenal permeability in patients with AP. Higher permeability in the descending duodenum was observed in severe than mild AP. Further large-scale studies are needed to confirm the relationship between altered duodenal permeability and the severity of AP.

Vitamin D deficiency predicts severe acute pancreatitis.

The ability to predict the severity of disease is important to reduce morbidity and mortality in patients with acute pancreatitis (AP). Vitamin D deficiency has been associated with severity in various diseases. This study was conducted to assess vitamin D as a predictor of disease severity in patients with AP. Patients with AP were prospectively enrolled at Yonsei University Wonju College of Medicine from March 2015 to September 2017. Serum vitamin D was analyzed as soon as AP was diagnosed. The level of vitamin D was classified as normal (>20 ng/ml), insufficient (>10 and ≤20 ng/ml) or deficient (≤10 ng/ml). Among 242 patients with AP, the prevalence of vitamin D deficiency was 56.2%, and 28.5% of patients had vitamin D insufficiency. Serum vitamin D level was negatively correlated with severity indexes, such as the Atlanta classification, Computed Tomography Severity Index, Bedside Index for Severity of Acute Pancreatitis, and Ranson score. The prevalence of vitamin D deficiency increased with severity of AP according to the Atlanta classification. Vitamin D deficiency was the independent factor for predicting severe AP (OR 5.37, 95% CI 1.13-25.57, p = 0.015) and intensive care unit admission (OR 3.09, 95% CI 1.24-7.69, p = 0.035). Vitamin D deficiency is associated with increased severity of AP and is a predictor for intensive care unit admission.