Peripancreatic Infection Research Articles

Beyond the revised atlanta classification: a comprehensive review of the imaging assessment of acute pancreatitis and its complications.

While the Revised Atlanta Classification outlines the primary complications of acute pancreatitis, it is crucial to recognize additional factors that contribute to morbidity and mortality associated with acute pancreatitis. In this review, we discuss the imaging-based classification and staging of acute pancreatitis as described by the Revised Atlanta Classification, but also provide a comprehensive understanding of the pancreatic anatomy and its relation to surrounding structures, which is essential for imaging-based assessment of both acute pancreatitis and its complications. We further extend the discussion beyond common complications such as pseudocysts and walled-off necrosis to include lesser-known but significant complications such as peripancreatic infection, disconnected ductal disconnection syndrome, thrombosis, hemorrhage, and gastrointestinal complications. Additionally, illustrative examples are presented to highlight relevant points pertaining to real-life imaging assessment of acute pancreatitis and its complications.

A Comprehensive Study on the Diagnostic Value of Multi-Slice Computed Tomography for Peripancreatic Infection in Elderly With Severe Acute Pancreatitis.

This study investigated the diagnostic efficacy of multi-slice spiral computed tomography (MSCT) perfusion imaging in evaluating peripancreatic infection in elderly patients with severe acute pancreatitis (SAP). A retrospective analysis was conducted on the clinical data of 110 elderly SAP patients treated at our hospital from March 2018 to August 2019. The study correlated MSCT perfusion imaging characteristics with peripancreatic infection in elderly SAP patients. Additionally, receiver operating characteristic (ROC) curves were constructed to assess the diagnostic performance of MSCT perfusion imaging parameters in evaluating peripancreatic infection in elderly SAP patients. The results indicated that among all 110 elderly SAP patients, the incidence rate of peripancreatic infection was 20.91%, with a mortality rate of 0.91%. MSCT perfusion imaging revealed that after peripancreatic infection in elderly SAP patients, there was a decrease in pancreatic density, local enlargement of the pancreas, blurring of the pancreatic margins, and associated ascites. Compression/narrowing/occlusion of the splenic vein was observed in 22 patients, compression/narrowing/occlusion of the superior mesenteric vein in 17 patients, thickening/thrombosis of the portal vein in 19 patients, and collateral circulation in 21 patients. Compared to elderly SAP patients without peripancreatic infection, those with the infection showed prolonged peak times, reduced peak heights, and decreased blood flow. ROC analysis indicated that the combination of the three parameters (peak time, peak height, and blood flow) had higher specificity and area under the curve (AUC) than single parameters, with no significant difference in sensitivity between the combination and single parameters. In conclusion, combining the three key MSCT perfusion imaging parameters (peak time, peak height, and blood flow) can significantly enhance the predictive efficacy for the risk of peripancreatic infection in elderly SAP patients.

An early warning model for sepsis complicated with acute respiratory distress syndrome based on synthetic minority oversampling technique algorithm

To explore the independent risk factors of acute respiratory distress syndrome (ARDS) in patients with sepsis, establish an early warning model, and verify the predictive value of the model based on synthetic minority oversampling technique (SMOTE) algorithm. A retrospective case-control study was conducted. 566 patients with sepsis who were admitted to Jinan People's Hospital from October 2016 to October 2022 were enrolled. General information, underlying diseases, infection sites, initial cause, severity scores, blood and arterial blood gas analysis indicators at admission, treatment measures, complications, and prognosis indicators of patients were collected. The patients were grouped according to whether ARDS occurred during hospitalization, and the clinical data between the two groups were observed and compared. Univariate and binary multivariate Logistic regression analysis were used to select the independent risk factors of ARDS during hospitalization in septic patients, and regression equation was established to construct the early warning model. Simultaneously, the dataset was improved using the SMOTE algorithm to build an enhanced warning model. Receiver operator characteristic curve (ROC curve) was drawn to validate the prediction efficiency of the model. 566 patients with sepsis were included in the final analysis, of which 163 developed ARDS during hospitalization and 403 did not. Univariate analysis showed that there were statistically significant differences in age, body mass index (BMI), malignant tumor, blood transfusion history, pancreas and peripancreatic infection, gastrointestinal tract infection, pulmonary infection as the initial etiology, acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score, albumin (Alb), blood urea nitrogen (BUN), mechanical ventilation therapy, septic shock and length of intensive care unit (ICU) stay between the two groups. Binary multivariate Logistic regression analysis showed that age [odds ratio (OR) = 3.449, 95% confidence interval (95%CI) was 2.197-5.414, P = 0.000], pulmonary infection as the initial etiology (OR = 2.309, 95%CI was 1.427-3.737, P = 0.001), pancreas and peripancreatic infection (OR = 1.937, 95%CI was 1.236-3.035, P = 0.004), septic shock (OR = 3.381, 95%CI was 1.890-6.047, P = 0.000), SOFA score (OR = 9.311, 95%CI was 5.831-14.867, P = 0.000) were independent influencing factors of ARDS during hospitalization in septic patients. An early warning model was established based on the above risk factors: P1 = -4.558+1.238×age+0.837×pulmonary infection as the initial etiology+0.661×pancreas and peripancreatic infection+1.218×septic shock+2.231×SOFA score. ROC curve analysis showed that the area under the ROC curve (AUC) of the model for ARDS during hospitalization in septic patients was 0.882 (95%CI was 0.851-0.914) with sensitivity of 79.8% and specificity of 83.4%. The dataset was improved based on the SMOTE algorithm, and the early warning model was rebuilt: P2 = -3.279+1.288×age+0.763×pulmonary infection as the initial etiology+0.635×pancreas and peripancreatic infection+1.068×septic shock+2.201×SOFA score. ROC curve analysis showed that the AUC of the model for ARDS during hospitalization in septic patients was 0.890 (95%CI was 0.867-0.913) with sensitivity of 85.3% and specificity of 79.1%. This result further confirmed that the early warning model constructed by the independent risk factors mentioned above had high predictive performance. Risk factors for the occurrence of ARDS during hospitalization in patients with sepsis include age, pulmonary infection as the initial etiology, pancreatic and peripancreatic infection, septic shock, and SOFA score. Clinically, the probability of ARDS in patients with sepsis can be assessed based on the warning model established using these risk factors, allowing for early intervention and improvement of prognosis.

The Effect of Prophylactic Carbapenem Use on Outcomes in Acute Pancreatitis: A Systematic Review and Meta-Analysis.

This study aimed to determine the effect of prophylactic use of carbapenems for acute pancreatitis on clinical outcomes. It was conducted according to the preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by using the keywords "Pancrea * AND carbapenem OR imipenem OR ertapenem OR meropenem OR doripenem." Primer outcomes were mortality, surgical intervention, and pancreatic and non-pancreatic infection. Subgroup analyses were also performed to reduce the risk of bias. Ten studies with 4038 patients were included in the meta-analyses. While eight of ten were randomized controlled trials, two were observational studies. The prophylactic use of carbapenems had no statistically significant effect on mortality (OR=0.82, 95% CI=0.65-1.04, I²=0%) and surgical intervention. (OR=0.81, 95% CI=0.57-1.17, I²=0%). However, the real impact of prophylaxis on reducing the incidence of mortality and surgical intervention was uncertain due to the insufficient sample size. The prophylactic use of carbapenems was significantly associated with a lower risk of peripancreatic (OR=0.37, 95% CI=0.25-0.55, I²=61%) and non-pancreatic infection risk (OR=0.60, 95% CI=0.46-0.78, I²=65%). The definitions of infection in the articles were not clear, and the diagnostic approach to infection was based on subjective criteria. In addition, there was inadequate collateral damage and safety assessments. In high-quality studies with a low risk of bias, prophylactic carbapenems had no effect on peripancreatic infection (RR=1.54, 95% CI=0.65-3.47, I²=0%) and non-pancreatic infection (RR=0.72, 95% CI=0.48-1.07, I²=0%). Although there is a reduction in the infection risk, routine carbapenem use in acute pancreatitis cases should not be recommended based on current evidence. Cooperation with Infectious Disease specialists and developing diagnostic algorithms are required instead of routine prophylaxis to prevent infection, especially non-pancreatic infection.

A nationwide survey of acute pancreatitis:a report from 126 hospitals in China

Objective: To investigate the current status of acute pancreatitis(AP) diagnosis and treatment in hospitals of different levels in China. Methods: A cross-sectional survey was conducted. The Acute Pancreatitis Diagnosis and Treatment Practice Questionnaire was designed and sent to the members of the Group of Pancreatic Surgery Chinese Society of Chinese Medical Association Branch and some other hospitals online from 8th to 24th December, 2020. Observation indicators included general information, AP diagnosis and assessment, treatment strategies, follow-up information, and comparisons of clinical practice between 3A-level and non-3A-level hospitals were performed. Counting data was used χ 2 test or Fisher exact test. Results: A total of 126 valid questionnaires were collected in final analysis, of which 75.4% (95/126) were from 3A-level hospitals, 15.9%(20/126) and 8.7%(11/126)were from other third-level and second-level hospitals,respectively. Of all participants, 88.1% (111/126)used classic AP diagnostic criteria, and 88.1% (111/126)conducted severity assessment. The revised Atlanta classification and determinant-based classification were commonly used, accounting for 72.1%(80/111) and 22.5%(25/111), respectively. 70.6%(89/126)used predictive models, including APACHE Ⅱ score, imaging models(modified CT severity index or Balthazar scoring) and Ranson criteria. For patients with early pancreatic or peripancreatic infection, 75.4%(95/126) preferred antibiotic therapy, and for those with infected walled-off necrosis, 61.1% (77/126) preferred percutaneous catheter drainage.When surgical intervention required,preferred methods were laparoscopic transabdominal surgery(37.3%, 47/126) and open surgery(25.4%,32/126). 61.1%(77/126) accepted "delayed surgery" notion. 32.5%(41/126) routinely used the step-up approach. For mild biliary acute pancreatitis, 44.4%(56/126) underwent cholecystectomy during the same hospital admission. Regarding follow-up, ideal overall follow-up periods were 6 months(46.0%,57/124) and 12 months(33.1%, 41/124), and follow-up interval was 3 months(50.8%,63/124) and 1 month(23.4%, 29/124). Comparing clinical practice of AP between 3A-level hospitals and non-3A-level hospitals, we found that the former had a significantly higher proportion of annual AP admission number of over 100(34.7%(33/95) vs.12.9%(4/31), χ 2=5.372, P=0.020), and higher proportion of routine severity assessment(68.4%(65/95) vs. 35.5%(11/31), χ²=11.107, P=0.004), higher proportion of routine severity prediction(45.3%(43/95) vs. 12.9%(4/31), χ²=13.549, P=0.001). When surgical intervention required, the proportion of step-up approach was significantly higher(37.9%(36/95) vs.16.1%(5/31), χ 2=8.512, P=0.017). Significantly more participants preferred that follow-up should be completed by full-time staff(35.8%(34/95) vs. 22.6%(7/31), χ²=8.154, P=0.043) in 3-A level hospitals. Conclusions: The standardization of AP diagnosis is relatively high in China. However, standardized assessment of severity and prediction need to be further prompted, especially in non-3A-level hospitals. Regarding AP treatment, especially the minimally invasive intervention strategy would be the focus of the promotion of standardized AP practice in the future.

Value of modified objective Bedside Index for Severity in Acute Pancreatitis score in predicting the severity and prognosis of acute pancreatitis

Objective To investigate the value of modified objective Bedside Index for Severity in Acute Pancreatitis (BISAP) score (MBISAP) in predicting the severity and prognosis of acute pancreatitis (AP). Methods A retrospective analysis was performed for the data of 313 patients with AP who were treated in Affiliated Hospital of North Sichuan Medical College from June 2018 to June 2020, and the subjective indicator of mental state in BISAP score was removed. According to the scoring criteria for Computed Tomography Severity Index (CTSI), the degree of pancreatic necrosis was classified as 4 grades (0%, 0%-30%, 30%-50%, and > 50%) and was assigned a score of 0-3 points, respectively, and MBISAP score was determined by adding the above points, with the highest score of 7 points. According to the receiver operating characteristic (ROC) curve, the 313 patients with pancreatitis were divided into low-level MBISAP group (MBISAP Results There were significant differences between the two groups in age (Z=-5.480, P 0.05). In predicting peripancreatic infection in AP, MBISAP score had an AUC of 0.842 (95% CI: 0.796-0.880, P 2, MBISAP score was better than BISAP score (AUC=0.776) and was inferior to CTSI score (AUC=0.932) (both P 2, MBISAP score was similar to BISAP score (AUC=0.855) and CTSI score (AUC=0.829) (both P > 0.05). Conclusion MBISAP score is better than BISAP score in predicting the severity of AP patients and peripancreatic infection, and it also has a good value in predicting mortality and MODS in patients with AP. MBISAP score can evaluate the conditions of AP patients more accurately and objectively than BISAP score.

936 Detection of Infection in Fluid Collections Following Acute Pancreatitis With Positron Emission Tomography-Computed Tomography Using Fluorine-18 Fluorodeoxyglucose Labelled Autologous Leucocytes

Introduction: Early detection of infected necrosis / fluid collections in acute pancreatitis (AP) has important implications in treatment and outcome. The diagnosis of infection is usually confirmed by fine-needle aspiration (FNA) from the collection and microbial culture. We here report our experience on diagnostic accuracy of positron emission tomographycomputed tomography (PET-CT) with fluorine-18 fluorodeoxyglucose labelled autologous leucocytes (FDG-LAL) in detecting pancreatic / peripancreatic infection in patients with AP. Materials and methods: In this prospective study, 103 patients (75 male, 28 female) aged 18-76 (41 ± 12) years with a clinical diagnosis of AP with pancreatic / peri-pancreatic fluid collections were investigated after taking an informed consent. Patients treated with antibiotics for 5 days or more were excluded. Leucocytes were separated from 40 ml of the patient's heparinized venous blood, labelled with FDG in vitro, suspended in the patient's own cellfree plasma and re-injected intravenously. Whole body PET-CT imaging was performed two hours later with oral and intravenous contrast (unless clinically contra-indicated). Focal, increased concentration of FDG-LAL in the pancreatic / peri-pancreatic collection was considered positive for infection. The scan diagnosis was compared with culture of FNA from the pancreatic / peripancreatic area under radiographic guidance within 24 hours. The sensitivity, specificity, accuracy, positive and negative predictive values of PET-CT in predicting infection were calculated. Results: Of the 103 patients , 57 had acute necrotic collections, 40 walledoff necrosis and 3 pseudocysts. Two others had normal pancreas and one a pancreatic mass (later diagnosed as a neuro-endocrine tumor); all three were scan-negative. Leucocyte labelling efficiency was 83±16%. 34/103 patients (33%) were culture-positive (CP) and 69/ 103 (67%) culture-negative (CN); 33/34 (97%) CP patients were PET-CT scan-positive for infection, while only 1/34 (3%) was scan-negative. The main infecting organisms were Escherichia coli and Pseudomonas aeruginosa. Of the 69 CN patients, 64 (93%) were negative and 5 (7%) positive on PET-CT. The sensitivity, specificity, accuracy, positive and negative predictive values of PET-CT in predicting infection were 97.1%, 92.8%, 94.9%, 86.8% and 98.5% respectively. No adverse effects were seen in any patient. Conclusion: PET-CT using FDG-LAL is a safe and accurate non-invasive imaging technique for detection and localization of infection in AP. Invasive aspiration could be avoided in scan-negative patients and FNA guided by this imaging technique may provide more accurate sampling for culture than CT alone.

Quantitative analysis of intestinal gas in patients with acute pancreatitis

Disturbance of gastrointestinal function is a common complication in the early phase of acute pancreatitis (AP). Intestinal gas may reflect the function of the gut. Using plain abdominal radiographs, we investigated whether intestinal gas volume is related to AP. Plain abdominal radiographs of 68 patients with AP within 24 hours after admission and 21 normal controls were digitized and transmitted to a computer. The region of intestinal gas was identified by an image manipulation software and the gas volume score (GVS) was calculated. The relationships between the GVS values and various clinical factors of AP were analyzed. The GVS in the AP group was 0.084+/-0.016, in the mild AP (MAP) group 0.070+/-0.005, and in the severe AP (SAP) group 0.094+/-0.013; all values were higher than that in the control group (P<0.01). The GVS in the SAP group was higher than that in the MAP group. The GVSs were correlated to the Ranson's scores (r=0.762, P<0.01) and the acute physiology and chronic health evaluation II (APACHE II) scores (r=0.801, P<0.01). In addition, the GVS in patients with secondary pancreatic and/or peripancreatic infection was 0.107+/-0.014, higher than that in patients without secondary infection (P<0.01). GVS was not related to gender, age, etiology or clinical outcome of AP. Intestinal gas volume is significantly elevated in patients with AP. It is closely related to Ranson's and APACHE II score and secondary pancreatic and/or peripancreatic infection. GVS may be a new prognostic tool for assessing the severity of AP in the early course of the disease.

Early goal-directed therapy in severe acute pancreatitis

Objective To study the difference in outcomes between two treatment regimens of goal-directed fluid therapy in patients with severe acute pancreatitis. Methods From January 2000 to January 2010, 80 patients with severe acute pancreatitis were assigned into 2 groups. In group A,patients received fluid therapy aiming at the following goals in 24 hours: (1) Blood pressure >90/60 mm Hg;(2) CVP between 8-12 mm Hg;(3) Urine output >0. 5 ml · kg-1 · h-1. In group B, patients received fluid therapy aiming at the following goals in 6 hours (according to SSC guideline,2004): (1) mean arterial blood pressure >65 mm Hg;(2) CVP between 8-12 mm Hg;(3) Urine output >0. 5 ml · kg-1 · h-1 ;(4) central venous oxygen saturation >70%. After therapy for 3 days we measured the Marshall score, APACHE Ⅱ score, and the peri-pancreatic infection and mortality rates. Results The Marshall score was 6. 82±4. 69 and 4. 48±3. 78 in group A and B, respectively (P=0. 02). The APACHE Ⅱ score was 11. 35±5. 96 and 8. 22±4. 53 in group A and B, respectively (P=0. 01). The peri-pancreatic infection rate was 44% and 37% in group A and B, respectively, and there was no significant difference between the 2 groups (P = 0. 65). The mortality rate was 24% and 17% in group A and B. There was no significant difference between the 2 groups(P=0. 57). Conclusion Goal-directed fluid therapy in patients with severe acute pancreatitis according to the SSC guideline improved organ function but it did not reduce peri-pancreatic infection and mortality rates. Key words: Severe acute pancreatitis; Fluid therapy; Early goal-directed therapy; Marshall score; APACHE Ⅱ score

Nosocomial peripancreatic infection associated with Shewanella xiamenensis

Shewanella xiamenensis, a newly established species originally from sea sediments, was repeatedly recovered from peripancreatic drainages in a patient and was the probable pathogen of hospital-acquired peripancreatic infection. A commercially available system misidentified it as Shewanella putrefaciens, suggesting that some previous reported cases with S. putrefaciens infection might have been caused by other Shewanella species. Precise species identification of Shewanella species usually requires gyrB sequencing.

Use of antibiotics in severe acute pancreatitis

Infectious complications in severe acute pancreatitis are an important problem and determine outcome in patients who survived the first inflammatory hit of the disease. Timely diagnosis of infected pancreatic necrosis is often challenging, but should not delay adequate treatment, which consists of source control and antibiotic treatment. Prophylactic antibiotics are not effective in reducing the incidence of (peri)pancreatic infection in patients with severe acute pancreatitis (or necrotizing pancreatitis). The only rational indication for antibiotics at this moment is documented infection. The spectrum of empiric antibiotics should cover both Gram-negative, Gram-positive and anaerobic microorganisms (also keeping in mind exposure to nosocomial microorganisms), and local ecology should be taken into account. Fungal infections are often present, and antifungal coverage should be considered, especially if multiple risk factors for invasive candidiasis are present. Currently, no tools are available to guide antimicrobial treatment.

Percutaneous catheter drainage in combination with choledochoscope-guided debridement in treatment of peripancreatic infection

To introduce and evaluate the new method used in treatment of pancreatic and peripancreatic infections secondary to severe acute pancreatitis (SAP). A total of 42 SAP patients initially underwent ultrasound-guided percutaneous puncture and catheterization. An 8-Fr drainage catheter was used to drain the infected peripancreatic necrotic foci for 3-5 d. The sinus tract of the drainage catheter was expanded gradually with a skin expander, and the 8-Fr drainage catheter was replaced with a 22-Fr drainage tube after 7-10 d. Choledochoscope-guided debridement was performed repeatedly until the infected peripancreatic tissue was effectively removed through the drainage sinus tract. Among the 42 patients, the infected peripancreatic tissue or abscess was completely removed from 38 patients and elective cyst-jejunum anastomosis was performed in 4 patients due to formation of pancreatic pseudocysts. No death and complication occurred during the procedure. Percutaneous catheter drainage in combination with choledochoscope-guided debridement is a simple, safe and reliable treatment procedure for peripancreatic infections secondary to SAP.

Magnetic resonance imaging for local complications of acute pancreatitis: A pictorial review

Acute pancreatitis is a common disease characterized by sudden upper abdominal pain and vomiting. Alcoholism and choledocholithiasis are the most common factors for this disease. The choice of treatment for acute pancreatitis might be affected by local complications, such as local hemorrhage in or around the pancreas, and peripancreatic infection or pseudoaneurysm. Diagnostic imaging modalities for acute pancreatitis have a significant role in confirming the diagnosis of the disease, helping detect the extent of pancreatic necrosis, and for diagnosing local complications. Magnetic resonance imaging (MRI) might be indicated in acute pancreatitis for detecting and characterizing local complications of acute pancreatitis that involve necrotic, hemorrhagic, infectious, vascular, and pseudocyst disorders. The general MRI sequences for pancreatitis require the combined use of T1-weighted, T2-weighted sequences, and magnetic resonance cholangiopancreatography. For imaging of pancreatic necrosis, the combination of T1-weighted and T2-weighted findings with dynamic contrast-enhanced imaging gives a comprehensive evaluation of the extent of necrosis and full range of inflammatory extension. For imaging of infectious complications, dynamic contrast-enhanced examinations might help differentiate pancreatic cellulitis or abscesses, from pancreatic fluid collection or simple pseudocysts. For vascular abnormalities, the combination of cross-sectional pancreatic parenchyma imaging with MRA represents a single diagnostic modality for the full evaluation of peripancreatic artery and vein involvement, such as arterial pseudoaneurysms and venous thromboses. The purpose of this pictorial review is to examine the MRI appearances of various local complications of acute pancreatitis and to discuss the practical setup of MRI in local complications of acute pancreatitis.

Comments on the article about the treatment of peripancreatic infection

We read with great interest the article by Tang et al published in issue 4 of World Journal of Gastroenterology 2010. The results of their study indicate that percutaneous catheter drainage in combination with choledochoscope-guided debridement is a simple, safe and reliable treatment procedure for peripancreatic infections secondary to severe acute pancreatitis. However, there are some points that need to be addressed, including data about the patients in the study and their clinical characteristics, data about infection and superinfection during the treatment and type of treatment of patients with acute necrotizing pancreatitis.

Clinical value of endoscopic placement of nasojejunal feeding tube for nutritional support in patients with severe acute pancreatitis

Objective To evaluate the clinical value of endoscopically nasojejunal feeding tube placement (ENFTP) for nutritional support in patients with severe acute pancreatitis (SAP). Methods Those SAP patients who treated with ENFTP (n= 47) or with total parenteral nutrition (TPN) (n=50) were retrospectively analyzed for laboratory parameters before and 1,2 and 4 weeks after nutrition support. Outcomes in the two groups were compared with respect to complications,mortality, duration of feeding, feeding costs,mechanical ventilation time and length of ICU or hospital stay. Results Four weeks after nutrition sypport, the hemoglobin and albumin were increased in ENFTP group as compared to TPN groups (P < 0. 05), while the blood sugar was decreased significant in ENFTP group than in TPN group (P<0.05). The incidence of peripancreatic or biliary infection and catheter-related infection were lower in ENFTP group than in TPN group. Duration of feeding and hospital stay were shorter, and nutrition cost was lower in ENFTP group (P<0.05). In addition, the APACHE Ⅱ score was significantly improved in ENFTP group(P<0.05). Conclusion ENFTP seems to be safe and less expensive in treatment of patients with acute pancreatitis. Key words: Pancreatitis, acute necrotizing; Enteral nutrition; Parenteral nutrition, total

Prophylactic antibiotic treatment in acute necrotizing pancreatitis: Results from a meta-analysis

Objective. The effect of prophylactic antibiotic treatment on infection and survival of acute necrotizing pancreatitis (ANP) remains uncertain. The aim of this study was to assess the long-term efficacy of prophylactic antibiotic treatment for ANP. Material and methods. Searches were carried out of electronic databases including Medline, EMBASE, the Cochrane Controlled Trials Register, the Science Citation Index, and PubMed (updated to December 2007), and manual bibliographical searches were also conducted. A meta-analysis of all randomized controlled trials (RCTs) comparing prophylactic antibiotic treatment with placebo or no treatment was performed. Results. Eight RCTs including 540 patients were assessed. The outcomes included infected necrosis, death, non-pancreatic infection, surgical intervention, and length of hospital stay. Prophylactic antibiotic use leads to a significant reduction of infected necrosis (relative risk (RR) 0.69, 95% CI, 0.50–0.95; p=0.02), non-pancreatic infections (RR 0.66 95% CI, 0.48–0.91; p=0.01), and length of hospital stay (p=0.004) but was not associated with a statistically significant reduction in mortality (RR 0.76 95% CI, 0.50–1.18; p=0.22) and surgical intervention (RR 0.90 95% CI, 0.66–1.23; p=0.52). In a subgroup analysis, carbapenem was associated with a significant reduction in infected necrosis (p=0.009) and non-pancreatic infections (p=0.006), whereas other antibiotics were not. Conclusions. Prophylactic antibiotic treatment is associated with a significant reduction of pancreatic or peripancreatic infection, non-pancreatic infection, and length of hospital stay, but cannot prevent death and surgical intervention in acute necrotizing pancreatitis.

Continuous veno-venous haemofiltration in the treatment of severe acute pancreatitis: 6-year experience

Background. Continuous veno-venous haemofiltration (CVVH) could be reasonable for attenuation of systemic complications in severe acute pancreatitis (SAP). The aim of the study was implementation and feasibility assessment of the CVVH in the treatment protocol of SAP. Patients and methods. CVVH was applied to 111 SAP patients during 2000–2005. APACHE II, systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), serum lipase, C-reactive protein (CRP), complication rate and main outcomes were analysed comparing two periods. Results. Overall, 39 patients corresponded to Balthazar grade E SAP and 72 patients to necrotizing SAP (NSAP), with an average APACHE II score of 7 and 8.5, respectively, on admission. CVVH was started within 48h in 82% of patients. Duration of CVVH was significantly augmented in NSAP patients during the routine period, comprising 92h (p=0.006). The clinical presentation of SIRS and MODS was similar in both periods, with more initial pulmonary dysfunctions in NSAP (p=0.048). Peripancreatic infection decreased in the routine period; surgical interventions were performed in 34.8% vs 72.4% of patients. Hospital stay comprised on average 15.9 days for grade E SAP and 29.4 days for NSAP in the routine period, with overall mortality of 10.26% and 30.5%, respectively. Discussion. Application of CVVH in the treatment protocol of SAP is obscure due to relative invasiveness, a poorly understood mechanism of action and scarce clinical experience. We conclude that early pre-emptive application of CVVH is safe and feasible in the treatment of SAP. Duration of the procedure seems to be essential. Randomized clinical trials are justified. Our results are in favour of clinical application of CVVH in the treatment of SAP.

Early Antibiotic Treatment for Severe Acute Necrotizing Pancreatitis

In patients with severe, necrotizing pancreatitis, it is common to administer early, broad-spectrum antibiotics, often a carbapenem, in the hope of reducing the incidence of pancreatic and peripancreatic infections, although the benefits of doing so have not been proved. A multicenter, prospective, double-blind, placebo-controlled randomized study set in 32 centers within North America and Europe. One hundred patients with clinically severe, confirmed necrotizing pancreatitis: 50 received meropenem and 50 received placebo. Meropenem (1 g intravenously every 8 hours) or placebo within 5 days of the onset of symptoms for 7 to 21 days. Primary endpoint: development of pancreatic or peripancreatic infection within 42 days following randomization. Other endpoints: time between onset of pancreatitis and the development of pancreatic or peripancreatic infection; all-cause mortality; requirement for surgical intervention; development of nonpancreatic infections within 42 days following randomization. Pancreatic or peripancreatic infections developed in 18% (9 of 50) of patients in the meropenem group compared with 12% (6 of 50) in the placebo group (P = 0.401). Overall mortality rate was 20% (10 of 50) in the meropenem group and 18% (9 of 50) in the placebo group (P = 0.799). Surgical intervention was required in 26% (13 of 50) and 20% (10 of 50) of the meropenem and placebo groups, respectively (P = 0.476). This study demonstrated no statistically significant difference between the treatment groups for pancreatic or peripancreatic infection, mortality, or requirement for surgical intervention, and did not support early prophylactic antimicrobial use in patients with severe acute necrotizing pancreatitis.

Bacterial analysis of infected pancreatic necrosis and its prevention (Symposium 8: Pancreatobiliary infection (IHPBA)).

In severe acute pancreatitis, sepsis mainly due to pancreatic or peripancreatic infection have emerged as the most serious complications and now accounts for more than 80% of deaths. Collective review of organisms associated with secondary pancreatic infection in patients with acute pancreatitis has revealed that most of them are intestinal flora. Several experimental studies including ours have revealed that acute pancreatitis promotes bacterial translocation (BT), which in turn leads to infection of the pancreas and septic complications. Prophylactic antibiotics given intravenously have been demonstrated to be beneficial in reducing the rate of pancreatic infection, but their survival benefit remains unclear. We have demonstrated that continuous regional arterial infusion (CRAI) of an antibiotic is more effective than intravenous administration in preventing pancreatic infection and improving survival, in a canine model of acute necrotizing pancreatitis. Our recent experimental study has revealed that CRAI of an antibiotic via the superior mesenteric artery (SMA) is effective in mitigating intestinal mucosal damage and preventing BT in acute pancreatitis, thereby improving survival. BT aggravates pancreatic necrosis and remote organ damage in acute pancreatitis, and SMA infusion of antibiotics is effective in preventing BT and is practical for clinical use.

Whole gut washout ameliorates the progression of acute experimental pancreatitis

Background: Septic complications are mainly responsible for deterioration of a patient with acute pancreatitis. Intestinal tract is accepted as the main source of pancreatic or peripancreatic infection. Material andmethods: Acute pancreatitis was induced in 40 Sprague-Dawley rats by ligation of the main biliopancreatic duct. Animals were divided into two groups. The first group of animals (n = 20) received high volume polyethylene glycol-3500 (GoLYTELY) for 6 hours through a silastic catheter introduced into the proximal part of the jejunum from a puncture gastrostomy during the initial laparotomy. The second group animals (n = 20) did not receive any treatment. Half of the animals from each group were sacrificed 72 hours later and tissue samples were taken from mesenteric lymph nodes, pancreas, spleen, and liver for bacteriologic cultures. Cecum cultures were also prepared. Blood samples at 72 hours were obtained for the measurement of amylase, lactic dehydrogenase (LDH), lactic acid, alanine aminotransferase (ALT), glucose, calcium, arterial pH, base excess, partial oxygen pressure, bicarbonate, leucocyte count, and hematocrit levels. The pancreas was examined histopathologically. The remaining half of the animals from each group were allowed to survive until death. Results: The levels of amylase, LDH, ALT, lactic acid, pH, pO 2, bicarbonate and base excess for the rats in group I were significantly lower when compared with the rats in group II ( P <0.05). Positive mesenteric lymph node cultures were detected in 30% of group I animals whereas they were positive in 90% of group II animals ( P = 0.0198). Distant organ cultures were positive in 8 animals (liver 5, spleen 2, pancreas 1) in group II, whereas only one positive distant organ culture (liver) was established in group I ( P >0.05). Histopathological scoring observed in the pancreas were less severe for the rats in group I when compared with the rats in group II ( P = 0.012). The rats in group I survived longer than the rats in group II (median survival 6.8 days versus 17.3 days, P <0.001). Conclusions: Whole gut washout with high-volume polyethylene glycol in pancreatitis reduced the blood levels of enzymes and increased the survival. Whole gut washout for acute pancreatitis appears effective to ameliorate the prognostic factors in blood and this modality may be a promising treatment method in acute pancreatitis.