Management Of Acute Pancreatitis Research Articles

急性膵炎診療ガイドライン2021改訂のポイント

急性膵炎診療ガイドライン2021改訂のポイント

Management of acute pancreatitis in the Emergency Department

Background: Heterogeneity in clinical manifestations and outcome of pancreatitis constitutes an obstacle for the creation of a common treatment algorithm by the scientific community.
 Aim: The aim of the present study was to systematically review the management of cases of acute pancreatitis in Emergency Department (ED) and her correlation with outcome.
 Methods: Search the database Pubmed and were included observational studies and randomized trials in adults in English.
 Results: The search yielded 13 studies. Of these, 3 concerned the diagnostic approach of the disease in ED and concluded that lipase is the most reliable test in diagnosis, while computed tomography of the abdomen is not recommended as a routine examination. 5 out of 13 studies analyzed the usefulness of disease severity classification systems, with the BISAP and HASP score appearing as reliable as the APACHE II and RANSON score, but having an advantage in rapid patient evaluation. The last 5, studied the need for immediate therapeutic / invasive method, with the time of surgery from the arrival at the ED being decisive as it affects the outcome of the disease. It is generally seen that the early invasive method is gaining ground in the treatment of the disease.
 Conclusion: The main goal is to predict the most severe forms of the disease in order to receive the right (invasive or not) treatment to improve survival and quality of life.

Evidence-Based Approach to the Surgical Management of Acute Pancreatitis.

Background Acute pancreatitis is a significant challenge to health services. Remarkable progress has been made in the last decade in optimizing its management. Methods This review is a comprehensive assessment of 7 guidelines employed in current clinical practice with an appraisal of the underlying evidence, including 15 meta-analyses/systematic reviews, 16 randomized controlled trials, and 31 cohort studies. Results Key tenets of early management of acute pancreatitis include severity stratification based on the degree of organ failure and early goal-directed fluid resuscitation. Rigorous determination of etiology reduces the risk of recurrence. Early enteral nutrition and consideration of epidural analgesia have been pioneered in recent years with promising results. Indications for invasive intervention are becoming increasingly refined. The definitive indications for endoscopic retrograde cholangiopancreatography in acute pancreatitis are associated with cholangitis and common bile duct obstruction. The role of open surgical necrosectomy has diminished with the development of a minimally invasive step-up necrosectomy protocol. Increasing use of endoscopic ultrasound-guided intervention in the management of pancreatic necrosis has helped reduce pancreatic fistula rates and hospital stay. Conclusion The optimal approach to surgical management of complicated pancreatitis depends on patient physiology and disease anatomy, in addition to the available resources and expertise. This is best achieved with a multidisciplinary approach. This review provides a distillation of the recommendations of clinical guidelines and critical discussion of the evidence that informs them and presents an algorithmic approach to key areas of patient management.

S66 Aggressive Intravenous Hydration in Patients With Acute Pancreatitis Is Beneficial Only During the First 24 Hours: A Meta-Analysis

Introduction: Early aggressive intravenous hydration (EAIH) remains the only initial treatment specifically for patients with acute pancreatitis. The timing, type, and amount of fluid remains the subject of study, debate, and controversy. In order to define our current state of knowledge of the clinical evidence behind the recommendation for EAIH, we performed a meta-analysis of the published literature. Methods: A Pubmed search to identify all clinical trials evaluating the role of EAIH in patients with acute pancreatitis resulted acute pancreatitis 25 studies, 17 prospective, 18 retrospective, 13 randomized controlled clinical trials (RCT). Studies that evaluated NS to LR were not included. In order to be included in the final analysis, the study needed to have two or more groups defined by different rates of hydration. One group must have included EAIH and define the outcome(s) studied. Outcomes used in our analysis included SIRS, pancreatic necrosis, persistent organ failure, length of stay, ICU admission, and mortality. Any decrease in these outcomes compared to the “control” groups was considered a “benefit”. The weighted mean for each study was defined by the sample size. Results: In a pooled analysis of all studies (n=1865), there was no difference in morbidity or mortality between EAIH and the “control group” (RR 1.1, 95% CI 0.66-1.8). When including only RCT (n=987), there was also no difference in morbidity or mortality (RR 0.88, 95% CI 0.78-1.4). However, when including studies and RCT that focused only on EAIH within the first 24 hours, excluding all studies that defined EAIH as the amount of fluid provided at 48 hours, there was a “benefit” to EAIH (RR 0.62, 95% CI 0.44-0.84). Conclusion: Our results show that the benefit observed in EAIH occurs only within 24 hours of enrollment. While guidelines on the management of acute pancreatitis have generally recommended EAIH, some have suggested that “goal directed therapy” is preferred due to complications. Our study demonstrates that it is important for clinicians caring for patients with acute pancreatitis not miss the “goal” within the first day of managing patients with acute pancreatitis. Our meta-analysis shows aggressive intravenous hydration after the first 24 hours is not beneficial and may be harmful. Based on this analysis, we suggest EAIH be applied to all patients during the first 24 hours and “goal directed” hydration after the first 24 hours.

S43 Role of Residents’ Didactics in Improving Management of Acute Pancreatitis: A Quality Improvement Project

S43 Role of Residents’ Didactics in Improving Management of Acute Pancreatitis: A Quality Improvement Project

Inflammatory bowel disease does not alter the clinical features and the management of acute pancreatitis: A prospective, multicentre, exact-matched cohort analysis

Objective and aimsAcute pancreatitis in inflammatory bowel disease occurs mainly as an extraintestinal manifestation or a side effect of medications. We aimed to investigate the prognostic factors and severity indicators of acute pancreatitis and the treatment of patients with both diseases. DesignWe performed a matched case-control registry analysis of a multicentre, prospective, international acute pancreatitis registry. Patients with both diseases were matched to patients with acute pancreatitis only in a 1:3 ratio by age and gender. Subgroup analyses were also carried out based on disease type, activity, and treatment of inflammatory bowel disease. ResultsNo difference in prognostic factors (laboratory parameters, bedside index of severity in acute pancreatitis, imaging results) and outcomes of acute pancreatitis (length of hospitalization, severity, and local or systemic complications) were detected between groups. Significantly lower analgesic use was observed in the inflammatory bowel disease population. Antibiotic use during acute pancreatitis was significantly more common in the immunosuppressed group than in the non-immunosuppressed group (p = 0.017). However, none of the prognostic parameters or the severity indicators showed a significant difference between any subgroup of patients with inflammatory bowel disease. ConclusionNo significant differences in the prognosis and severity of acute pancreatitis could be detected between patients with both diseases and with pancreatitis only. The need for different acute pancreatitis management is not justified in the coexistence of inflammatory bowel disease, and antibiotic overuse should be avoided.

Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis

BackgroundEarly aggressive hydration is widely recommended for the management of acute pancreatitis, but evidence for this practice is limited.MethodsAt 18 centers, we randomly assigned patients who presented with acute pancreatitis to receive goal-directed aggressive or moderate resuscitation with lactated Ringer’s solution. Aggressive fluid resuscitation consisted of a bolus of 20 ml per kilogram of body weight, followed by 3 ml per kilogram per hour. Moderate fluid resuscitation consisted of a bolus of 10 ml per kilogram in patients with hypovolemia or no bolus in patients with normovolemia, followed by 1.5 ml per kilogram per hour in all patients in this group. Patients were assessed at 12, 24, 48, and 72 hours, and fluid resuscitation was adjusted according to the patient’s clinical status. The primary outcome was the development of moderately severe or severe pancreatitis during the hospitalization. The main safety outcome was fluid overload. The planned sample size was 744, with a first planned interim analysis after the enrollment of 248 patients.ResultsA total of 249 patients were included in the interim analysis. The trial was halted owing to between-group differences in the safety outcomes without a significant difference in the incidence of moderately severe or severe pancreatitis (22.1% in the aggressive-resuscitation group and 17.3% in the moderate-resuscitation group; adjusted relative risk, 1.30; 95% confidence interval [CI], 0.78 to 2.18; P=0.32). Fluid overload developed in 20.5% of the patients who received aggressive resuscitation and in 6.3% of those who received moderate resuscitation (adjusted relative risk, 2.85; 95% CI, 1.36 to 5.94, P=0.004). The median duration of hospitalization was 6 days (interquartile range, 4 to 8) in the aggressive-resuscitation group and 5 days (interquartile range, 3 to 7) in the moderate-resuscitation group.ConclusionsIn this randomized trial involving patients with acute pancreatitis, early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes. (Funded by Instituto de Salud Carlos III and others; WATERFALL ClinicalTrials.gov number, NCT04381169.)

Epidural Analgesia for Pain Management in Acute Pancreatitis during Pregnancy and Its Effect on Maternal and Fetal Outcome.

Background Acute pancreatitis (AP) during pregnancy is a rare presentation with an estimated incidence of 1 case per 1000 to 10,000 pregnancies. Severe epigastric and abdominal pain is the earliest and the most common symptom of AP, and adequate pain relief is an integral part of patient management. The aim of our study was to investigate the different pain relief modalities that are used in pregnant women with AP and the efficacy of each method used, in terms of better pain relief and maternal-fetal outcomes. Methods This was a retrospective observational study over a period of 6 years conducted at a tertiary care hospital. Pregnant women with clinical and biochemical diagnoses of acute pancreatitis were included in the study. Patient's history and clinical and biochemical data were collected from the medical records of the hospital. Results A total of 12 patients were included in the study, 5 out of 12 patients had gall stones associated with AP, 2 patients had hypertriglyceridemia, and 1 each had preeclampsia and eclampsia. Epidural analgesia at the level of L1-L2 spinal level showed a reduction of VAS scores from 8 or 9 to 1 or 2, indicating excellent pain as compared to t intravenous (i/v) infusion of fentanyl or i/v boluses of injection tramadol, in whom VAS was never reduced below 3. With satisfactory results, labour analgesia and anesthesia for caesarean section was provided via the same catheter in 2 and 3 patients, respectively. Maternal and fetal outcomes were comparable in all the patients. Conclusion AP in pregnancy, when diagnosed early and managed accordingly, leads to better maternal and fetal outcomes. Epidural analgesia was better than intravenous analgesia in terms of pain management and better recovery of acute pancreatitis patients. In these patients, labour analgesia and anesthesia for caesarean section can be provided through the same catheter, making it a potential novel modality in the treatment of acute pancreatitis in pregnancy.

Racial/Ethnic Disparities in the Management of Pediatric Acute Pancreatitis Across Children's Hospitals.

Racial or ethnic disparities in health care delivery and resource utilization have been reported in a variety of pediatric diseases. In acute pancreatitis (AP), there is an association between Black race and increased inpatient mortality. Data on the association of race and ethnicity and resource use for managing pediatric AP are lacking. The aim of this study is to investigate this potential association in pediatric AP. Retrospective study of children 0-18 years diagnosed with AP in the Pediatric Health Information System (PHIS) database from 2012 to 2018. Descriptive statistics were used to summarize cohort characteristics. Race/ethnicity classifications included non-Hispanic Black (NHB), non-Hispanic White (NHW, used as reference), Hispanic, and "Other." Associations between patient characteristics and race/ethnicity were determined using χ2 tests. Generalized linear mixed regression model was used to determine the association of race/ethnicity with odds of resource utilization, costs, and length of hospital stay after adjusting for covariates with a random intercept for site. Five thousand nine hundred sixty-three patients from 50 hospitals were included. Adjusted analysis showed that NHB children hospitalized with AP were at lower odds of receiving opioids in the first 24 hours [adjusted odds ratio (aOR) = 0.82, 95% confidence interval (CI) = 0.70-0.98] and receiving intravenous fluids during the hospitalization (aOR = 0.64, 95% CI = 0.43-0.96) when compared with NHW children. Additionally, NHB and Hispanic children had a prolonged adjusted mean length of hospital stay and higher hospital costs when compared with NHW children. Although there was no significant association between race/ethnicity and diagnosis of pancreatic necrosis or sepsis, Hispanic and "Other" children were at higher odds of receiving antibiotics during hospitalization for AP (aOR = 1.33, 95% CI = 1.13-1.57 and aOR = 1.37, 95% CI = 1.09-1.73, respectively) than NHW children. Disparities exist in utilization of health care interventions for pediatric AP patients by race/ethnicity. Future studies should investigate why these disparities exist and if these disparities affect outcomes.

Management of Acute Biliary Pancreatitis in Cholecystectomized Patients

Management of Acute Biliary Pancreatitis in Cholecystectomized Patients

Revised Clinical Practice Guidelines of the Korean Pancreatobiliary Association for Acute Pancreatitis.

Acute pancreatitis can range from a mild, self-limiting disease requiring no more than supportive care, to severe disease with life-threatening complications. With the goal of providing a recommendation framework for clinicians to manage acute pancreatitis, and to contribute to improvements in national health care, the Korean Pancreatobiliary Association (KPBA) established the Korean guidelines for acute pancreatitis management in 2013. However, many challenging issues exist which often lead to differences in clinical practices. In addition, with newly obtained evidence regarding acute pancreatitis, there have been great changes in recent knowledge and information regarding this disorder. Therefore, the KPBA committee underwent an extensive revision of the guidelines. The revised guidelines were developed using the Delphi method, and the main topics of the guidelines include the following: diagnosis, severity assessment, initial treatment, nutritional support, convalescent treatment, and the treatment of local complications and necrotizing pancreatitis. Specific recommendations are presented, along with the evidence levels and recommendation grades.

Diagnosis and Management of Acute Pancreatitis in Pregnancy.

Acute pancreatitis is rare in pregnancy; however, the associated morbidity and mortality make prompt diagnosis and appropriate management essential. 1,2 Although most cases are mild and improve with limited interventions, severe cases require a multidisciplinary approach in a critical care setting. The main principles of management include identification of an etiology to guide therapy, fluid resuscitation, electrolyte repletion, early nutritional support, and pain management. Antibiotics are not indicated for prophylaxis and should be reserved for cases with a suspected infectious process. Surgical management is indicated in select cases. Management in pregnant patients has few differences which are outlined below.

TH7.9 A retrospective audit of the investigation and management of acute pancreatitis (AP) in a tertiary referral hospital in Ireland

Abstract Aims This audit aims to determine if standards of best practice according to NICE guideline pancreatitis (September 2018) are being met. Methods Using the Hospital In-Patient Enquiry (HIPE) system, 129 admissions with AP during 2020 were retrospectively identified. Audit targets included adequate fluid resuscitation and nutritional support, frequency of radiological investigations, emergency cholecystectomy, lifestyle advice and appropriate follow up. Results Aetiologies identified were biliary (33.3%), alcohol (33.3%), idiopathic (7.8%), hypertriglyceridemia (3.8%), autoimmune (1.6%), medication (0.8%), anatomical variant (0.8%) and the remainder (18.6%) were unidentified since not fully investigated (NFI). 47.3% (n=61) had ultrasound while 61.2% (n=79) had computed tomography of abdomen and pelvis (CTAP) during hospital-stay. Out of 33.3% (n=43) with biliary aetiology, 25.6% (n=11) had successful ERCP and 41.9% (n=18) were referred for outpatient clinic or already awaiting outpatient laparoscopic cholecystectomy. No emergency cholecystectomies were performed. Out of 28 readmissions, biliary pathology accounted for 35.7% (n=10), alcohol 25% (n=7) and NFI 17.9% (n=5). 37.2% (16) of alcoholic pancreatitis admissions had documented cessation advice either as in-patient or on discharge. There was no documentation for HbA1C in 6 months or DEXA scan in 2 years’ time, or a yearly fecal elastase for chronic pancreatitis patients. Conclusion Audit of current practice identified areas for improvement, including bettering access to emergency theatre, increased focus on encouraging lifestyle modification and monitoring pancreatic endocrine and exocrine function. We aim to create an institutional standard operating procedure for investigating and managing pancreatitis, and re-audit next year to discern if management has moved closer to the established standard.

WE2.8 Improving Management for Acute Cholecystitis and Biliary Pancreatitis – the ‘Hot Gallbladder Pathway’

Abstract Aim There is a wide variation between National Health Service (NHS) hospitals in the management of patients with acute cholecystitis and biliary pancreatitis. 20–33% of patients will make repeat visits to hospital with gallstone-related symptoms before any surgical intervention performed. We established a ‘Hot Gallbladder Pathway’ with the aim for improving outcome and decreasing complications of these patients. The aim of this quality improvement project was to assess if a district general hospital (DGH) could provide a safe and effective ‘hot gallbladder’ service with a clear pathway. Method Quality improvement methods were used to integrate the ‘hot gallbladder pathway’ to manage patients with acute calculous cholecystitis and biliary pancreatitis. A prospective observational study with strict inclusion/ exclusion criteria and secure online data was conducted during a 13-month period. The data were then compared against existing National Institute for Health and Clinical Excellence (NICE) guidelines and further changes were recommended. Results We achieved almost 70% of the patients undergoing emergency laparoscopic cholecystectomy in both group of patients who met the pathway criteria within the expected time frame, compared with the pre-implementation result of 23% and national average of only 16% in England. None of the patients suffered from intraoperative complications or 30-day mortality. Conclusion A clear ‘hot gall bladder pathway’ is effective at improving care for patients requiring emergency laparoscopic cholecystectomy and potentially useful for other acute Trusts which their standard is below the NICE guideline.

A Nano-Liposomal Formulation of Caffeic Acid Phenethyl Ester Modulates Nrf2 and NF-κβ Signaling and Alleviates Experimentally Induced Acute Pancreatitis in a Rat Model.

The currently available management strategies for acute pancreatitis are inadequately effective which calls for exploration of new approaches to treat this condition. Caffeic acid phenethyl ester (CAPE) is a major bioactive constituent of honeybee propolis with promising therapeutic and preventive applications. However, its pharmaceutical potential and clinical use are hindered by its poor water solubility and limited plasma stability. In this study, we aimed to prepare, characterize and evaluate a CAPE-loaded nanoliposomal formulation to improve the efficacy of CAPE for the management of acute pancreatitis. The CAPE-loaded nanoliposomes (CAPE-loaded-NL) were prepared by a thin layer evaporation technique and were optimized using three edge activators. CAPE-loaded-NL were characterized for their vesicle size (VS), zeta potential (ZP), encapsulation efficiency (EE), polydispersity index (PDI), crystalline state and morphology. The protective effect of the optimal CAPE-loaded-NL was evaluated in a rat model of acute pancreatitis induced by administering a single intraperitoneal injection of L-ornithine. Oral pretreatment with CAPE-loaded-NL significantly counteracted ornithine-induced elevation in serum activities of pancreatic digestive enzymes and pancreatic levels of malondialdehyde, nuclear factor kappa B (NF-κB) p65, tumor necrosis factor-alpha, nitrite/nitrate, cleaved caspase-3 and myeloperoxidase activity. Moreover, pretreatment with CAPE-loaded-NL significantly reinstated the ornithine-lowered glutathione reductase activity, glutathione, nuclear factor erythroid 2-related factor 2 (Nrf2), heme oxygenase-1 levels and ATP/ADP ratio, and potentiated the Bcl-2/Bax ratio in pancreatic tissue. CAPE-loaded-NL displayed superior antioxidant, anti-inflammatory and anti-apoptotic effects compared to free CAPE oral suspension and achieved a more potent correction of the derangements in serum amylase and pancreatic myeloperoxidase activities. The histological observations were in line with the biochemical findings. Our results suggest that CAPE-loaded-NL provide a promising interventional approach for acute pancreatitis mainly through the enhancement of the exerted antioxidant, anti-inflammatory and anti-apoptotic effects which may be mediated, at least in part, through modulation of Nrf2 and NF-κβ signaling.

Readmissions After Biliary Acute Pancreatitis: Analysis of the Nationwide Readmissions Database.

BackgroundAcute pancreatitis is a common inflammatory condition that involves the pancreas. Gallstones and alcohol are the most common etiologies in the USA. Cholecystectomy is the cornerstone procedure in the management of biliary acute pancreatitis (BAP). In this study, we examined the causes and predictors of readmissions following BAP based on the procedure performed.MethodsUsing the Nationwide Readmissions Database (NRD) and the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD10-CM/PCS), we retrospectively studied BAP hospitalizations (2016 - 2018). The first hospitalization within the year was marked as index hospitalization. Index hospitalizations were categorized based on whether an endoscopic retrograde cholangiopancreatography (ERCP) and/or a cholecystectomy was performed into no procedure group, ERCP group, cholecystectomy group, and both procedures group. We subsequently identified readmissions within 30 days. Using this categorization, we studied reasons, rates, and predictors of readmissions.ResultsA total of 127,318 index hospitalizations were included. The cholecystectomy group constituted the largest share of this cohort (43.5%). Using the no procedure group as a reference, analysis of the outcomes showed that the cholecystectomy group had the lowest inpatient mortality (adjusted odds ratio (aOR): 0.18, P < 0.001), while both procedures group had the highest total hospital charges (adjusted mean difference (aMD): 42,249, P < 0.001). Acute pancreatitis without necrosis or infection was the most frequent principal diagnosis for readmission (18.7%). Analysis of readmission predictors showed that both procedures group had the lowest risk for readmission (adjusted hazard ratio (aHR): 0.40, P < 0.001). Females were less likely to be readmitted compared to males (aHR: 0.82, P < 0.001) and elderly were less likely to be readmitted compared to young adults (aHR: 0.82, P < 0.001). Patients discharged against medical advice were more likely to be readmitted (aHR: 1.76, P < 0.001).ConclusionUndergoing both ERCP and cholecystectomy for BAP resulted in significantly higher hospital charges with no additional mortality benefit. However, it decreased the readmission risk significantly. Acute pancreatitis without necrosis or infection was the most frequent reason for readmissions.

Acute pancreatitis in 60 Iranian children: do pediatricians follow the new guidelines in diagnosis and management of acute pancreatitis?

BackgroundThe incidence of acute pancreatitis in children is increasing, but causes and diagnostic and therapeutic methods are various in different centers. The aim of this study was to investigate the common causes and routine diagnostic and therapeutic methods of acute pancreatitis in children in a pediatric gastrointestinal referral center and its accordance with existing guidelines.MethodsIn this retrospective, cross-sectional study, a total of 60 children with a diagnosis of acute pancreatitis, were studied.ResultsThe most common causes of acute pancreatitis were systemic and metabolic diseases and medications. CT scan was performed for 36% of patients, but 31% of patients, for whom a CT scan was performed had no clear indication of CT scan. Only half of the patients received fluid 1.5 times their maintenance in the first 24 h. Antibiotic therapy was performed for 48% of patients but medical indications for antibiotic treatment were found in only 34% of cases. During the COVID-19 pandemic, the relative incidence of acute pancreatitis was increased.ConclusionsIn children with systemic and metabolic disease and using anticonvulsant drugs, it is important to consider the incidence of this disease. In clinical education, the risks of radiation due to unnecessary CT scans and inappropriate prescription of antibiotics need to be emphasized. More research should be done to study the association between COVID-19 and acute pancreatitis.

A procalcitonin-based algorithm to guide antibiotic use in patients with acute pancreatitis (PROCAP): a single-centre, patient-blinded, randomised controlled trial

Differentiating inflammation from bacterial infection in patients with acute pancreatitis can be difficult. Procalcitonin can distinguish infection from inflammation, and algorithms based on procalcitonin measurement can differentiate bacterial sepsis from a systemic inflammatory response. We aimed to test the hypothesis that a procalcitonin-based algorithm to guide initiation, continuation, and discontinuation of antibiotics could lead to reduced antibiotic use without an adverse effect on outcome in acute pancreatitis. PROCAP was a single-centre, patient-blinded, randomised controlled trial done at the Manchester Royal Infirmary (Manchester, UK). Eligible participants were aged 18 years or older and had a clinical diagnosis of acute pancreatitis. Participants were randomly assigned (1:1) to procalcitonin-guided care or usual care using web-based randomisation software. The randomisation sequence was stratified by disease severity and admission pathway, using variable block sizes of 4, 6, or 8. Patients, but not clinicians, were masked to group assignment. In the procalcitonin-guided care group, procalcitonin testing was conducted on days 0, 4, 7, and weekly thereafter. Guidance was to stop or not start antibiotics following a test value of less than 1·0 ng/mL and to start or continue antibiotics following a test value of 1·0 ng/mL or more. In the intervention group, any empirical clinical decision to use antibiotics was preceded by measurement of procalcitonin. Otherwise, both groups received standard care. The primary outcome was use of antibiotics during the index admission to hospital. All analyses were done in the intention-to-treat population. This study was registered with the International Standard Randomised Controlled Trial registry, ISRCTN 50584992. Between July 29, 2018, and Nov 13, 2020, 369 patients were screened, of whom 260 were enrolled and randomly assigned to a treatment group (132 to procalcitonin-guided care and 128 to usual care). 59 (45%) of patients in the procalcitonin-guided care group were prescribed antibiotics compared with 79 (63%) in the usual care group (adjusted risk difference -15·6% [95% CI -27·0 to -4·2]; p=0·0071). The odds ratio for the treatment effect was 0·49 (95% CI 0·29 to 0·83; p=0·0077). There was no significant difference between groups in terms of the number of clinical infections or hospital-acquired infections per patient. Four (3%) patients in the procalcitonin-guided care group and three (2%) patients in the usual care group died; all deaths were related to underlying severe pancreatitis. There was no difference in adverse events between the groups. Our findings suggest that procalcitonin-guided care can reduce antibiotic use without increasing infection or harm in patients with acute pancreatitis. Procalcitonin-based algorithms to guide antibiotic use should be considered in the care of this group of patients and be incorporated into future guidelines on the management of acute pancreatitis. None.

CoMpliAnce with evideNce-based cliniCal guidelines in the managemenT of acute biliaRy pancreAtitis): The MANCTRA-1 international audit

Background/objectivesReports about the implementation of recommendations from acute pancreatitis guidelines are scant. This study aimed to evaluate, on a patient-data basis, the contemporary practice patterns of management of biliary acute pancreatitis and to compare these practices with the recommendations by the most updated guidelines. MethodsAll consecutive patients admitted to any of the 150 participating general surgery (GS), hepatopancreatobiliary surgery (HPB), internal medicine (IM) and gastroenterology (GA) departments with a diagnosis of biliary acute pancreatitis between 01/01/2019 and 31/12/2020 were included in the study. Categorical data were reported as percentages representing the proportion of all study patients or different and well-defined cohorts for each variable. Continuous data were expressed as mean and standard deviation. Differences between the compliance obtained in the four different subgroups were compared using the Mann-Whitney U, Student's t, ANOVA or Kruskal-Wallis tests for continuous data, and the Chi-square test or the Fisher's exact test for categorical data. ResultsComplete data were available for 5275 patients. The most commonly discordant gaps between daily clinical practice and recommendations included the optimal timing for the index CT scan (6.1%, χ2 6.71, P = 0.081), use of prophylactic antibiotics (44.2%, χ2 221.05, P < 0.00001), early enteral feeding (33.2%, χ2 11.51, P = 0.009), and the implementation of early cholecystectomy strategies (29%, χ2 354.64, P < 0.00001), with wide variability based on the admitting speciality. ConclusionsThe results of this study showed an overall poor compliance with evidence-based guidelines in the management of ABP, with wide variability based on the admitting speciality.Study protocol registered in ClinicalTrials.Gov (ID Number NCT04747990).

Quality of life after surgical and endoscopic management of severe acute pancreatitis: A systematic review.

BACKGROUNDTreatment for severe acute severe pancreatitis (SAP) can significantly affect Health-related quality of life (HR-QoL). The effects of different treatment strategies such as endoscopic and surgical necrosectomy on HR-QoL in patients with SAP remain poorly investigated. AIMTo critically appraise the available evidence on HR-QoL following surgical or endoscopic necrosectomy in patient with SAP. METHODSA literature search was performed on PubMed, Google™ Scholar, the Cochrane Library, MEDLINE and Reference Citation Analysis databases for studies that investigated HR-QoL following surgical or endoscopic necrosectomy in patients with SAP. Data collected included patient characteristics, outcomes of interventions and HR-QoL-related details. RESULTSEleven studies were found to have evaluated HR-QoL following treatment for severe acute pancreatitis including 756 patients. Three studies were randomized trials, four were prospective cohort studies and four were retrospective cohort studies with prospective follow-up. Four studies compared HR-QoL following surgical and endoscopic necrosectomy. Several metrics of HR-QoL were used including Short Form (SF)-36 and EuroQol. One randomized trial and one cohort study demonstrated significantly improved physical scores at three months in patients who underwent endoscopic necrosectomy compared to surgical necrosectomy. One prospective study that examined HR-QoL following surgical necrosectomy reported some deterioration in the functional status of the patients. On the other hand, a cohort study that assessed the long-term HR-QoL following sequential surgical necrosectomy stated that all patients had SF-36 > 60%. In the only study that examined patients following endoscopic necrosectomy, the HR-QoL was also very good. Three studies investigated the quality adjusted life years suggesting that endoscopic and surgical approaches to management of pancreatic necrosis were comparable in cost effectiveness. Finally, regarding HR-QoL between open necrosectomy and minimally invasive approaches, patients who underwent the later had a significantly better overall quality of life, vitality and mental health. CONCLUSIONThis review would suggest that the endoscopic approach might offer better HR-QoL compared to surgical necrosectomy. However, the available comparative literature was very limited. More randomized trials powered to detect differences in HR-QoL are required.