Local Complications Of Acute Pancreatitis Research Articles

Recent Treatment Strategies for Acute Pancreatitis.

Acute pancreatitis (AP) is a leading gastrointestinal disease that causes hospitalization. Initial management in the first 72 h after the diagnosis of AP is pivotal, which can influence the clinical outcomes of the disease. Initial management, including assessment of disease severity, fluid resuscitation, pain control, nutritional support, antibiotic use, and endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis, plays a fundamental role in AP treatment. Recent updates for fluid resuscitation, including treatment goals, the type, rate, volume, and duration, have triggered a paradigm shift from aggressive hydration with normal saline to goal-directed and non-aggressive hydration with lactated Ringer's solution. Evidence of the clinical benefit of early enteral feeding is becoming definitive. The routine use of prophylactic antibiotics is generally limited, and the procalcitonin-based algorithm of antibiotic use has recently been investigated to distinguish between inflammation and infection in patients with AP. Although urgent ERCP (within 24 h) should be performed for patients with gallstone pancreatitis and cholangitis, urgent ERCP is not indicated in patients without cholangitis. The management approach for patients with local complications of AP, particularly those with infected necrotizing pancreatitis, is discussed in detail, including indications, timing, anatomical considerations, and selection of intervention methods. Furthermore, convalescent treatment, including cholecystectomy in gallstone pancreatitis, lipid-lowering medications in hypertriglyceridemia-induced AP, and alcohol intervention in alcoholic pancreatitis, is also important for improving the prognosis and preventing recurrence in patients with AP. This review focuses on recent updates on the initial and convalescent management strategies for AP.

APPLICATION OF MINI-INVASIVE ECHO-CONTROLLED PERCUTANEOUS INTERVENTIONS IN PATIENTS WITH A COMPLICATED COURSE OF ACUTE PANCREATITIS

Background. Mini-invasive percutaneous echo-controlled puncture drainage interventions have certain limitations in case of location of local complications of acute pancreatitis of the right and central-right type due to the high risk of iatrogenic injuries as a result of possible uncontrolled advancement of the working part of the device.
 Aim: to improve the results of surgical treatment of patients with acute pancreatitis through the introduction of improved techniques of miniinvasive percutaneous echo-controlled interventions in complicated course of the disease.
 Materials and methods. The study was based on the results of examination of 187 patients with severe acute pancreatitis, who were divided into two groups: a comparison group – patients who used traditional methods of examination and treatment (n=92) and the main group – patients who used improved surgical tactics (n =95). To assess the effectiveness of surgical tactics in the studied groups, a comparative analysis of the applied methods, the frequency of postoperative complications, mortality, and the duration of hospitalization was carried out.
 Results. The introduction of improved miniinvasive percutaneous echo-controlled surgical interventions expanded the possibilities of their use, including in the localization of infected local complications of the right and central-right type, and probably increased their effectiveness by 41.8% (p=0.02). A comparative analysis of the duration of inpatient treatment in the studied groups revealed a probable reduction in the terms of hospitalization of patients in the main group by 14.7 days (р=0.0008), of which in the intensive care unit – by 4.7 days (р<0.0001).
 Conclusion. The use of improved methods of diagnosis and treatment in patients of the main group made it possible to reliably reduce the frequency of postoperative complications by 28% (p=0.003) and overall postoperative mortality by 27.7% (p=0.005).

Lactated Ringer’s solution reduces severity, mortality, systemic and local complications in acute pancreatitis: systematic review and meta-analysis

Lactated Ringer’s solution reduces severity, mortality, systemic and local complications in acute pancreatitis: systematic review and meta-analysis

Validation of the Revised Atlanta Criteria in determining the severity of acute pancreatitis.

Determining the severity of acute pancreatitis (AP) is crucial for patient management. The aim of our study was to assess the accuracy and limitations of the Revised Atlanta Criteria (RAC) in determining the severity of AP. The study was retrospectively conducted on AP patients admitted to the Gastroenterology Department of Sakarya University Faculty of Medicine. The severity, morphology and local complications of AP were evaluated according to the RAC. Laboratory parameters, clinical scores predicting disease severity and Computer Tomography Severity Index scores were assessed. The study group included 113 patients. Ninety-eight (86.7%) had interstitial edematous, and 15 (13.3%) had necrotizing pancreatitis. AP pancreatitis was mild in 69 (61.1%), moderate in 33 (29.2%), and severe in 11 (9.7%). Compared to the moderate group, patients in the severe group had a higher hematocrit, creatinine, SIRS and BISAP scores at admission and more length of hospital stay, more ICU requirements, and higher mortality rates ( P < 0.05). Eleven patients had single or multiple persistent organ failure (POF). The mortality rate of patients who developed early POF (n = 6) was higher compared to the group of patients who developed late POF (n = 2) (83.3% and 40%, respectively). Severity assessment using the RAC in patients with AP is consistent with laboratory parameters and scoring systems predicting severity. Severe pancreatitis cases who develop early POF may be classified separately.

Local complications of acute pancreatitis and methods of their instrumental diagnosis

The literature review considers the characteristics of local complications in the classifications of acute pancreatitis, as well as analyzed the effectiveness of modern methods of their diagnosis. Understanding the morphology of changes occurring in the pancreas and parapancreatic tissue in acute pancreatitis is of great importance, as it often determines the tactics of surgical treatment. Modern diagnostic methods for local complications of acute pancreatitis, such as contrast-enhanced ultrasound, endoscopic ultrasound, computed tomography, magnetic resonance imaging and cholangiopancreatography are highly informative, but the effectiveness of their use depends on the duration of the disease and the type of local complications, which makes to apply the differentiated approach to their use.

Time to think prime times for treatment of necrotizing pancreatitis: A pendulum conundrum.

Pancreatic fluid collections (PFCs) typically develop as local complications of acute pancreatitis and complicate the clinical course of acute pancreatitis patients with potentially fatal clinical outcomes. Interventions are required in cases of symptomatic walled-off necrosis (matured PFC with necrosis) and pancreatic pseudocysts (matured PFC without necrosis). In the management of necrotizing pancreatitis and walled-off necrosis, endoscopic ultrasound (EUS)-guided transluminal drainage combined with on-demand endoscopic necrosectomy (i.e., the step-up approach) is increasingly utilized as a less invasive treatment modality compared to a surgical or percutaneous approach. Through the substantial research efforts and development of specific devices and stents (e.g., lumen-apposing metal stents), endoscopic techniques of PFC management have been standardized to some extent. However, there has been no consensus about timing of carrying out each treatment step; for instance, it is uncertain when direct endoscopic necrosectomy should be initiated and finished, and when a plastic or metal stent should be removed following clinical treatment success. Despite emerging evidence for the effectiveness of non-interventional supportive treatment (e.g., antibiotics, nutritional support, irrigation of the cavity), there has been only a limited data on the timing of starting and stopping the treatment. Large studies are required to optimize the timing of those treatment options and improve clinical outcomes of patients with PFCs. In this review, we summarize the current available evidence on the indications and timing of interventional and supportive treatment modalities for this patient population and discussed clinical unmet needs that should be addressed in future research.

Lactated Ringer's Solution Reduces Severity, Mortality, Systemic and Local Complications in Acute Pancreatitis: A Systematic Review and Meta-Analysis.

Fluid therapy is the cornerstone of early supportive therapy in acute pancreatitis (AP). Regrettably, the type of fluid is still debated among clinicians, despite recent evidence from randomized controlled trials (RCTs). We aimed to incorporate all evidence from RCTs comparing lactated Ringer's solution (LR) with normal saline (NS) in adult and pediatric AP patients, with particular emphasis on clinically relevant outcomes. We evaluated RCTs comparing intravenous fluid resuscitation with LR to NS in adult or pediatric AP patients according to a prospectively registered protocol (CRD42021224542). Moderate-to-severe AP (MSAP), mortality, length of hospitalization (LoH), need for intensive care, the incidence of systemic (organ failure, OF) and local complications (in total), necrosis and pseudocyst formation were analyzed separately. Risk ratio (RR) and median difference (MD) were calculated with 95% confidence intervals (CI) using a random effect model. Risk of bias and quality of evidence were assessed. Altogether, 8 eligible RCTs were found, including 557 patients (LR: 278; NS: 279). LR reduced the risk of MSAP by 31% (RR: 0.59, 95% CI: 0.36-0.97, high quality) and the risk of death by 62% (RR: 0.48; 95% CI: 0.24-0.98, very low quality). LR was associated with a significantly lower risk of need for intensive care (RR: 0.50, 95% CI: 0.33-0.77), OF (RR: 0.78, 95% CI: 0.61-0.99) and local complications (RR: 0.64, 95% CI: 0.46-0.89). No significant risk reduction was observed for LoH (MD: -0.57 days, CI: -1.33-0.19), necrosis, pseudocyst and inflammatory parameters by LR compared to NS. LR reduces severity, mortality, need of intensive care and systemic and local complications in AP.

Echoendoscopy-guided drainage of pancreatic collections using self-expanding metallic prosthesis: a retrospective observational cross-sectional study

Background: Pancreatic fluid collections are local complications of acute pancreatitis. Advances in research and the development of new techniques to address local complications have allowed minimally invasive therapeutic options. Endoscopic ultrasound-guided drainage is currently the procedure of choice. Objective: To describe the results of the placement of a self-expanding metallic prosthesis for echoendoscopy-guided drainage of pancreatic collections in patients. Methods: This study followed a retrospective observational cross-sectional model (STROBE rules). The study was sent and approved by the Institutional Ethics Committee of the Federal University of the State of Rio de Janeiro, Brazil. For data analysis, descriptive statistical analysis (mean and standard deviation), non-parametric analysis (Kruskal-Wallis, with p&lt;0.05 with a statistical difference in CI95%), and parametric analysis (One-Way Anova, with p&gt;0.05 with a statistical difference in CI95%), and logistic regression analysis, with p&lt;0.05 with statistical significance in CI95%. Results: Thirteen patients were referred for drainage of collections, and 4 patients were excluded. Of the 9 patients studied, there was a predominance of males (7:2) with a mean age of 54.5 years. Eight patients had walled-off necrosis (WON). The device used was the Hot AxiosTM self-expanding luminal apposition metallic prosthesis, which was inserted uneventfully in all patients. Complete resolution of the condition was found in 88.8% of cases. After logistic regression analysis between the categorical predictors (Gender and Age) versus the response predictors (Necrosectomy, Review Interval, and Stent Permanence), it was observed that certain Gender or Age can influence the response predictors. Conclusion: Drainage of pancreatic collections using minimally invasive techniques is a safe and effective procedure.

局所合併症に対する外科治療

局所合併症に対する外科治療

Outcome assessment of surgical management of local complications of acute pancreatitis: An observational study

Aim: To evaluate the indication and outcome of different surgical management modalities in local complications of acute pancreatitis. Methodology: A hospital-based observational study was conducted in the department of surgery Shri Shankaracharya Institute of medical sciences, Bhilai, India after approval from the institutional ethical committee. A purposive sampling method was utilized to recruit the patients. Patients who underwent laparoscopic or open surgical procedures transperitoneal or retroperitoneal for the management of local complications of acute pancreatitis for the period of 1 year were included. Clinical, laboratory and imaging findings including, contrast-enhanced CT scan findings of all the cases, were recorded as per the proforma. In addition, the indication of each procedure, perioperative outcome and associated complications were evaluated in all the studied cases. All minimally invasive procedures were performed under general anesthesia by the surgical team experienced in pancreatic surgery. Results: Total 496 patients were admitted to the surgery department with the diagnosis of acute pancreatitis or with complications of acute pancreatitis. Among them, 80 patients had local complications due to acute pancreatitis. All patients were managed using the step-up approach, starting with conservative management and minimally invasive intervention when warranted. 24 patients required surgical intervention due to failure of endoscopic or radiological intervention or positions of lesions being inaccessible to these techniques. Among the 24 patients in the study, 4 patients had PPC, all of whom were managed with external drainage due to persistent symptoms. 6 patients who had ANC were initially subjected to conservative management. In addition, WON was noted in 4 patients and 10 patients had pseudocyst. Due to clinical deterioration and high suspicion of infected necrosis in patients with WON, FNAC was performed in all patients, revealing growth in culture. Conclusion: Patients who have local complications of pancreatitis respond best to treatment at a tertiary care centre that is staffed with pancreatic surgeons. Surgery is still the primary treatment option for pancreatic necrosis and pancreatic fluid collection, despite the proliferation of endoscopic procedures designed to treat these conditions.

Revised Clinical Practice Guideline of Korean Pancreatobiliary Association for Acute Pancreatitis: Treatment of Local Complication and Necrotizing Pancreatitis

In severe acute pancreatitis, accompanied by local complications such as acute peripancreatic fluid collection, pancreatic pseudocyst, acute necrotic collection and walled-off necrosis, the mortality rate is as high as 12-25%. In many cases, interventional procedure or surgical treatment are required at an appropriate time. Conservative treatment is considered for acute peripancreatic fluid collection. Endoscopic drainage could be considered preferentially for the treatment of pancreatic pseudocysts with clinical symptoms or complications. In the case of necrotizing pancreatitis, conservative treatment is preferred, but therapeutic intervention should be considered if infectious pancreatic necrosis with clinical deterioration is suspected. For therapeutic intervention, it is recommended to proceed with a step-up approach in which drainage is first performed and, if necessary, necrosectomy is performed. The optimal timing of intervention is considered 4 weeks after the onset of pancreatitis when necrosis become walled-off, but early drainage within 4 weeks can be considered depending on the patient's condition. This guideline provides an overview of current treatment strategies for local complications of acute pancreatitis.

Progress in research of minimally invasive therapy of local complications of acute pancreatitis

Progress in research of minimally invasive therapy of local complications of acute pancreatitis

Direct Endoscopic Necrosectomy: Timing and Technique.

Walled-off pancreatic necrosis (WOPN) is one of the local complications of acute pancreatitis (AP). Several interventional techniques have been developed over the last few years. The purpose of this narrative review is to explore such methodologies, with specific focus on endoscopic drainage and direct endoscopic necrosectomy (DEN), through evaluation of their indications and timing for intervention. Findings indicated how, after the introduction of lumen-apposing metal stents (LAMS), DEN is becoming the favorite technique to treat WOPN, especially when large solid debris or infection are present. Additionally, DEN is associated with a lower adverse events rate and hospital stay, and with improved clinical outcome.

The role of comorbid hypertriglyceridemia and abdominal obesity in the severity of acute pancreatitis: a retrospective study

BackgroundThe effect of comorbid hypertriglyceridemia (HTG) and abdominal obesity (AO) on acute pancreatitis (AP) remains unclear. The aim of this study was to explore the effect of comorbid HTG and AO and discuss which is the dominant disorder.MethodsIn this study, 1219 AP patients who presented with HTG or AO were stratified into four groups: non-HTG + non-AO, HTG + non-AO, non-HTG + AO, and HTG + AO.ResultsThe 328 patients with comorbid HTG + AO were much younger (42.29 ± 11.77), mainly male (79.57%), and had higher TG levels, larger waist circumferences, and more past medical histories than the patients in the other three non-comorbid groups (P < 0.001). The comorbidity group developed more incidences of persistent organ failure and local complications (P < 0.05). Multivariate logistic regression analysis showed that AO (OR = 3.205, 95% CI = 1.570–6.544), mild HTG (OR = 2.746, 95% CI = 1.125–6.701), and moderate to very severe HTG (OR = 3.649, 95% CI = 1.403–9.493) were independent risk factors for persistent respiratory failure (P < 0.05). Age > 60 years (OR = 1.326, 95% CI = 1.047–1.679), AO (OR = 1.701, 95% CI = 1.308–2.212), diabetes mellitus (OR = 1.551, 95% CI = 1.063–2.261), mild HTG (OR = 1.549, 95% CI = 1.137–2.112), and moderate to very severe HTG (OR = 2.810, 95% CI = 1.926–4.100) were independent risk factors associated with local complications (P < 0.05). Moreover, HTG seemed to be more dangerous than AO. The higher the serum TG level was, the greater the likelihood of persistent respiratory failure and local complications.ConclusionsComorbid HTG and AO will aggravate the severity and increase the incidence of local complications of AP. HTG may play a dominant role of risk in the condition of comorbidity.Chinese clinical trial registryChiCTR2100049566. Registered on 3rd August, 2021. Retrospectively registered, https://www.chictr.org.cn/edit.aspx?pid=127374&htm=4.

Indications and outcome of surgical management of local complications of acute pancreatitis: a single-centre experience

Background: Acute pancreatitis is a common and challenging disease that can develop both local and systemic complications. According to the Atlanta classification, local complications include peri-pancreatic collection, acute necrotic collection, pseudocyst and walled-off necrosis.Methods: A hospital-based retrospective study was conducted in the department of surgery at Kathmandu medical college teaching hospital. Patients were recruited using purposive sampling method and those who underwent laparoscopic, retroperitoneal or open surgical procedures for the management of local complications of acute pancreatitis from June 2017 to July 2021. The indication, perioperative outcome and associated complications were evaluated in all the cases.Results: Between June 2017 to July 2021, 432patients were admitted to the surgery department with acute pancreatitis or with complications of acute pancreatitis. Twenty-one patients required surgical intervention in the form of external drainage, cysto-enterostomy, VARD or open necrosectomy due to failure of endoscopic or radiological intervention or due to positions of lesions being inaccessible to these techniques. All patients had clinical improvement following surgery with an acceptable complication rate given the severity of the disease.Conclusions: Although various endoscopic techniques are now available to manage the pancreatic fluid collection and pancreatic necrosis, surgery remains essential in managing the disease.

S71 Prevalence and Outcomes of Local Complications in Acute Pancreatitis: A Review of Nationwide Inpatient Data

S71 Prevalence and Outcomes of Local Complications in Acute Pancreatitis: A Review of Nationwide Inpatient Data

Technical aspects of minimally invasive percutaneous approach for local complications of acute pancreatitis

Aim. To improve the results of treatment for patients with acute pancreatitis by optimizing the technique of performing percutaneous methods of drainage and sequestrectomy.Material and methods. We have considered experience of treating pancreatic necrosis in 257 patients, confirmed by computed tomography, intraoperatively, and postmortem examinations. Moderate severity pancreatitis was detected in 159 (61.9%) patients, severe – in 98 (38.1%) cases.Results. Small focal pancreatic necrosis was detected in 99 (62.3%) patients with moderate pancreatitis, large focal pancreatitis – in 60 (37.7%). Small-focal pancreatic necrosis was in 23 (23.5%) patients, large-focal – in 43 (43.9%), subtotal – in 29 (29.6%), total – in 3 (3.1%) among patients with severe acute pancreatitis. Percutaneous approach was used in combination with transluminal and open surgery in 59 (23%) patients. Infected necrosis was detected in 6 (3.8%) patients with acute moderate pancreatitis and in 44 (44.9%) patients with severe pancreatitis, sepsis – in 12 (12.2%) patients. 27 (10.5%) patient have died from septic shock in the first phase of pancreatitis, included 14 (5.4%) cases after surgery. Overall 41 (16%) patients with pancreatic necrosis have died.Conclusion. Compliance of stages in surgical treatment technology allows optimally combine it with transluminal sequestrectomy, reduces surgical trauma, eliminates additional risks of open approach associated with complications and deaths.

Decreased circulating retinol binding protein is an independent risk factor for local complications of acute pancreatitis

Decreased circulating retinol binding protein is an independent risk factor for local complications of acute pancreatitis

Current status of treatments of pancreatic and peripancreatic collections of acute pancreatitis.

Pancreatic and peripancreatic collections are the main local complications of acute pancreatitis with a high incidence. In the early phase, most acute pancreatic and peripancreatic collections can resolve spontaneously with supportive treatment. However, in some cases, they will develop into pancreatic pseudocyst (PPC) or walled-off necrosis (WON). When causing symptoms or coinfection, both PPC and WON may require invasive intervention. Compared to PPC, which can be effectively treated by endoscopic ultrasound-guided transmural drainage with plastic stents, the treatment of WON is more complicated and challenging, particularly in the presence of infected necrosis. In the past few decades, with the development of minimally invasive interventional technology especially the progression of endoscopic techniques, the standard treatments of those severe complications have undergone tremendous changes. Currently, based on the robust evidence from randomized controlled trials, the step-up minimally invasive approaches have become the standard treatments for WON. However, the pancreatic fistulae during the surgical step-up treatment and the stent-related complications during the endoscopic step-up treatment should not be neglected. In this review article, we will mainly discuss the indications of PPC and WON, the timing for intervention, and minimally invasive treatment, especially endoscopic treatment. We also introduced our preliminary experience in endoscopic gastric fenestration, which may be a promising innovative method for the treatment of WON.

Early occurrence of pseudocysts in acute pancreatitis – A multicenter international cohort analysis of 2275 cases

BackgroundPseudocysts being the most frequent local complications of acute pancreatitis (AP) have substantial effect on the disease course, hospitalization and quality of life of the patient. Our study aimed to understand the effects of pre-existing (OLD-P) and newly developed (NEW-P) pseudocysts on AP. MethodsData were extracted from the Acute Pancreatitis Registry organized by the Hungarian Pancreatic Study Group (HPSG). 2275 of 2461 patients had uploaded information concerning pancreatic morphology assessed by imaging technique. Patients were divided into “no pseudocyst” (NO-P) group, “old pseudocyst” (OLD-P) group, or “newly developed pseudocyst” (NEW-P) groups. ResultsThe median time of new pseudocyst development was nine days from hospital admission and eleven days from the beginning of the abdominal pain. More NEW-P cases were severe (15.9% vs 4.7% in the NO-P group p < 0.001), with longer length of hospitalization (LoH) (median: 14 days versus 8 days, p < 0.001), and were associated with several changed laboratory parameters. OLD-P was associated with male gender (72.2% vs. 56.1%, p = 0.0014), alcoholic etiology (35.2% vs. 19.8% in the NO-P group), longer hospitalization (median: 10 days, p < 0.001), a previous episode of AP (p < 0.001), pre-existing diagnosis of chronic pancreatitis (CP) (p < 0.001), current smoking (p < 0.001), and increased alcohol consumption (unit/week) (p = 0.014). ConclusionMost of the new pseudocysts develop within two weeks. Newly developing pseudocysts are associated with a more severe disease course and increased length of hospitalization. Pre-existing pseudocysts are associated with higher alcohol consumption and smoking. Because CP is more frequently associated with a pre-existing pseudocyst, these patients need closer attention after AP.