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Gao CC, Li J, Cao F, Wang XH, Li A, Wang Z, Li F. Infection recurrence following minimally invasive treatment in patients with infectious pancreatic necrosis. World J Gastroenterol 2020; 26:3087-3097. [PMID: 32587450 PMCID: PMC7304114 DOI: 10.3748/wjg.v26.i22.3087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/27/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In recent decades, an increasing number of patients have received minimally invasive intervention for infected pancreatic necrosis (IPN) because of the benefits in reducing postoperative multiple organ failure and mortality. However, there are limited published data regarding infection recurrence after treatment of this patient population.
AIM To investigate the incidence and prediction of infection recurrence following successful minimally invasive treatment in IPN patients.
METHODS Medical records for 193 IPN patients, who underwent minimally invasive treatment between February 2014 and October 2018, were retrospectively reviewed. Patients, who survived after the treatment, were divided into two groups: one group with infection after drainage catheter removal and another group without infection. The morphological and clinical data were compared between the two groups. Significantly different variables were introduced into the correlation and multivariate logistic analysis to identify independent predictors for infection recurrence. Sensitivity and specificity for diagnostic performance were determined.
RESULTS Of the 193 IPN patients, 178 were recruited into the study. Of them, 9 (5.06%) patients died and 169 patients survived but infection recurred in 13 of 178 patients (7.30%) at 7 (4-10) d after drainage catheters were removed. White blood cell (WBC) count, serum C-reactive protein (CRP), interleukin-6, and procalcitonin levels measured at the time of catheter removal were significantly higher in patients with infection than in those without (all P < 0.05). In addition, drainage duration and length of the catheter measured by computerized tomography scan were significantly longer in patients with infection (P = 0.025 and P < 0.0001, respectively). Although these parameters all correlated positively with the incidence of infection (all P < 0.05), only WBC, CRP, procalcitonin levels, and catheter length were identified as independent predictors for infection recurrence. The sensitivity and specificity for infection prediction were high in WBC count (≥ 9.95 × 109/L) and serum procalcitonin level (≥ 0.05 ng/mL) but moderate in serum CRP level (cut-off point ≥ 7.37 mg/L). The catheter length (cut-off value ≥ 8.05 cm) had a high sensitivity but low specificity to predict the infection recurrence.
CONCLUSION WBC count, serum procalcitonin, and CRP levels may be valuable for predicting infection recurrence following minimally invasive intervention in IPN patients. These biomarkers should be considered before removing the drainage catheters.
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Affiliation(s)
- Chong-Chong Gao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Jia Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Feng Cao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Xiao-Hui Wang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Zhe Wang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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Minimally invasive treatment of infected pancreatic necrosis. GASTROENTEROLOGY REVIEW 2014; 9:317-24. [PMID: 25653725 PMCID: PMC4300346 DOI: 10.5114/pg.2014.47893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 08/25/2012] [Accepted: 11/15/2012] [Indexed: 12/13/2022]
Abstract
Infected pancreatic necrosis is a challenging complication that worsens prognosis in acute pancreatitis. For years, open necrosectomy has been the mainstay treatment option in infected pancreatic necrosis, although surgical debridement still results in high morbidity and mortality rates. Recently, many reports on minimally invasive treatment in infected pancreatic necrosis have been published. This paper presents a review of minimally invasive techniques and attempts to define their role in the management of infected pancreatic necrosis.
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Madenci AL, Michailidou M, Chiou G, Thabet A, Fernández-del Castillo C, Fagenholz PJ. A contemporary series of patients undergoing open debridement for necrotizing pancreatitis. Am J Surg 2014; 208:324-31. [PMID: 24767969 DOI: 10.1016/j.amjsurg.2013.11.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 11/11/2013] [Accepted: 11/11/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND For patients with acute pancreatitis complicated by infected necrosis, minimally invasive techniques have taken hold without substantial comparison with open surgery. We present a contemporary series of open necrosectomies as a benchmark for newer techniques. METHODS Using a prospective database, we retrospectively identified consecutive patients undergoing debridement for necrotizing pancreatitis (2006 to 2009). The primary endpoint was in-hospital mortality. RESULTS Sixty-eight patients underwent debridement for pancreatic/peripancreatic necrosis. In-hospital mortality was 8.8% (n = 6). Infection (n = 43, 63%) and failure-to-thrive (n = 13, 19%) comprised the most common indications for necrosectomy. The false negative rate (FNR) for infection of percutaneous aspirate was 20.0%. Older age (P = .02), Acute Physiology and Chronic Health Evaluation II score upon admission (P = .03) or preoperatively (P < .01), preoperative intensive care unit admission (P = .01), and postoperative organ failure (P = .03) were associated with mortality. CONCLUSIONS Open debridement for necrotizing pancreatitis results in a low mortality, providing a useful comparator for other interventions. Given the high FNR of percutaneous aspirate, debridement should not be predicated on proven infection.
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Affiliation(s)
- Arin L Madenci
- Department of Surgery, Division of Trauma Emergency Surgery and Critical Care, Boston, MA 02114, USA
| | - Maria Michailidou
- Department of Surgery, Division of Trauma Emergency Surgery and Critical Care, Boston, MA 02114, USA
| | - Grace Chiou
- Department of Surgery, Division of Trauma Emergency Surgery and Critical Care, Boston, MA 02114, USA
| | - Ashraf Thabet
- Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Boston, MA 02114, USA
| | | | - Peter J Fagenholz
- Department of Surgery, Division of Trauma Emergency Surgery and Critical Care, Boston, MA 02114, USA.
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Seifert GJ, Poxleitner PJ, Richter SC, Hopt UT, Wittel UA. Dissecting the effect of moxifloxacin in mice with infected necrosis in taurocholate induced necrotizing pancreatitis. Pancreatology 2014; 14:179-85. [PMID: 24854613 DOI: 10.1016/j.pan.2014.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 02/05/2014] [Accepted: 02/13/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To investigate the limited benefit of antibiotics in ameliorating the outcome of acute necrotizing pancreatitis, we analyzed antibiotic therapy in primarily infected necrotizing pancreatitis in mice with respect to the local pancreatic pathology as well as systemic, pancreatitis induced adverse events. METHODS Sterile pancreatic necrosis (SN) was induced by retrograde injection of 4% taurocholate in the common bile duct of Balb/c mice. Primarily infected pancreatic necrosis (IN) was induced by co-injecting 10(8) CFU/ml Escherichia coli. 10 mg/kg of moxifloxacin was administered prior to pancreatitis induction (AN). After 24 h, animals were sacrificed to examine serum as well as organs for signs of SIRS. RESULTS Moxifloxacin significantly reduced bacterial count in pancreatic lysates of animals with infected pancreatic necrosis (IN 4.1·10(7) ± 2.4·10(7) vs. AN 4.9·10(4) ± 2.6·10(4) CFU/g; p < 0.001). However, it did not alter pancreatic histology or pulmonary damage (Histology score: IN 23.8 ± 2.7 vs. AN 22.6 ± 1.7). Moxifloxacin reduced systemic immunoactivation (Serum IL-6: IN 330.5 ± 336.6 vs. 38.7 ± 25.5 pg/ml; p < 0.001), hypoglycemia (serum glucose: IN 105.8 ± 12.7 vs. AN 155.7 ± 39.5 mg/dl; p < 0.001), and serum aspartate aminotransferase (IN 606 ± 89.7 vs. AN 255 ± 52.1; p < 0.05). These parameters were significantly increased in animals with necrotizing pancreatitis. CONCLUSION In the experimental setting, initial antibiotic therapy with moxifloxacin in acute infected necrotizing pancreatitis in mice does not have a beneficial impact on pancreatic pathology or pulmonary damage. However, other systemic complications induced by infected necrosis in acute pancreatitis are reduced by the administration of moxifloxacin.
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Affiliation(s)
- Gabriel J Seifert
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Philipp J Poxleitner
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Sabine C Richter
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Ulrich T Hopt
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Uwe A Wittel
- Department of General and Visceral Surgery, Universitätsklinik Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany.
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Armstrong JA, Cash N, Soares PMG, Souza MHLP, Sutton R, Criddle DN. Oxidative stress in acute pancreatitis: lost in translation? Free Radic Res 2013; 47:917-33. [PMID: 23952531 DOI: 10.3109/10715762.2013.835046] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Oxidative stress has been implicated in the pathogenesis of acute pancreatitis, a severe and debilitating inflammation of the pancreas that carries a significant mortality, and which imposes a considerable financial burden on the health system due to patient care. Although extensive efforts have been directed towards the elucidation of critical underlying mechanisms and the identification of novel therapeutic targets, the disease remains without a specific therapy. In experimental animal models of acute pancreatitis, increased oxidative stress and decreased antioxidant defences have been observed, changes also detected in patients clinically. However, despite the promise of studies evaluating the effects of antioxidants in these model systems, translation to the clinic has thus far been disappointing. This may reflect many factors involved in the design of both preclinical and clinical evaluations of antioxidant therapy, not least the fact that most experimental studies have focussed on pre-treatment rather than post-injury assessment. This review has examined evidence relating to the involvement of oxidative stress in the pathophysiology of acute pancreatitis, focussing on experimental models and the clinical experience, including the experimental techniques employed and potential of antioxidant therapy.
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Affiliation(s)
- J A Armstrong
- NIHR Liverpool Pancreas Biomedical Research Unit, RLBUHT , Liverpool , UK
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6
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Gou S, Xiong J, Wu H, Zhou F, Tao J, Liu T, Wang C. Five-year cohort study of open pancreatic necrosectomy for necotizing pancreatitis suggests it is a safe and effective operation. J Gastrointest Surg 2013; 17:1634-1642. [PMID: 23868057 DOI: 10.1007/s11605-013-2288-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Accepted: 07/05/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Despite advances in the management of necrotizing pancreatitis, open necrosectomy remains an important management option for necrotizing pancreatitis, and patients undergoing necrosectomy suffer significant morbidity and mortality. The aim of this study was to report the outcomes of open necrosectomy from a recent large cohort of patients with necrotizing pancreatitis. METHODS Data are reported from a cohort of 276 consecutive patients with necrotizing pancreatitis who underwent open surgical debridement. Nutritional status, nutritional methods, bleeding, infection, demarcation of necrotic tissues, and time from onset of disease were scored. Scores ≥ 10 were considered as an indication for debridement. RESULTS One hundred sixty-two (58.7%) and 52 (18.8%) patients underwent minimally invasive peritoneal and retroperitoneal drainage, respectively, before necrosectomy. Median delay from disease onset to debridement was 48 days. Fifty-five patients (19.9%) underwent more than one operation; 352 operations were performed in total. There were 17 deaths (6.2%) postoperatively. CONCLUSION This study demonstrated the results for open debridement in a recent large cohort of patients. Although minimally invasive necrosectomy has been developed in recent years, open necrosectomy remains an important approach for the debridement of necrotizing pancreatitis effectively and safely.
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Affiliation(s)
- Shanmiao Gou
- Pancreatic Disease Institute, Department of General Surgery, Union Hospital, HUST, Wuhan, China
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7
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Minimally invasive necrosectomy versus conventional surgery in the treatment of infected pancreatic necrosis: a systematic review and a meta-analysis of comparative studies. Surg Laparosc Endosc Percutan Tech 2013; 23:8-20. [PMID: 23386143 DOI: 10.1097/sle.0b013e3182754bca] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM The purpose of this meta-analysis and systematic review is to compare minimally invasive necrosectomy (MIN) versus open necrosectomy (ON) surgery for infected necrosis of acute pancreatitis. METHODS One randomized controlled trial and 3 clinical controlled trials were selected, with a total of 336 patients (215 patients who underwent MIN and 121 patients underwent ON) included after searching in the following databases: Medline, Embase, Cochrane Central Register of Controlled Trials, BioMed Central, Science Citation Index (from inception to August 2011), Greynet, SIGLE (System for Information on Grey Literature in Europe), National Technological Information Service, British Library Integrated catalogue, and the Current Controlled Trials. Statistical analysis is performed using the odds ratio (OR) and weighted mean difference with 95% confidence interval (CI). RESULTS After the analysis of the data amenable to polling, significant advantages were found in favor of the MIN in terms of: incidence of multiple organ failure (OR, 0.16; 95% CI, 0.06-0.39) (P < 0.0001), incisional hernias (OR, 0.23; 95% CI, 0.06-0.90) (P = 0.03), new-onset diabetes (OR, 0.32; 95% CI, 0.12-0.88) (P = 0.03), and for the use of pancreatic enzymes (OR, 0.005; 95% CI, 0.04-0.57) (P = 0.005). No differences were found in terms of mortality rate (OR, 0.43; 95% CI, 0.18-1.05) (P = 0.06), multiple systemic complications (OR, 0.34; 95% CI, 0.01-8.60) (P = 0.51), surgical reintervention for further necrosectomy (OR, 0.16; 95% CI, 0.00-3.07) (P = 0.19), intra-abdominal bleeding (OR, 0.79; 95% CI, 0.41-1.50) (P = 0.46), enterocutaneous fistula or perforation of visceral organs (OR, 0.52; 95% CI, 0.27-1.00) (P = 0.05), pancreatic fistula (OR, 0.66; 95% CI, 0.30-1.46) (P = 0.30), and surgical reintervention for postoperative complications (OR, 0.50; 95% CI, 0.23-1.08) (P = 0.08). CONCLUSIONS The lack of comparative studies and high heterogeneity of the data present in the literature did not permit to draw a definitive conclusion on this topic. The results of the present meta-analysis might be helpful to design future high-powered randomized studies that compare MIN with ON for acute necrotizing pancreatitis.
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Zhou M, Chen B, Sun H, Chen X, Yu Z, Shi H, Yao J, Xu Z, Zhang Q, Andersson R. The efficiency of continuous regional intra-arterial infusion in the treatment of infected pancreatic necrosis. Pancreatology 2013; 13:212-215. [PMID: 23719590 DOI: 10.1016/j.pan.2013.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 02/15/2013] [Accepted: 02/16/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Our aim was to investigate the efficiency of continuous regional intra-arterial infusion (CRAI) with antisecretory agents and antibiotics in the treatment of infected pancreatic necrosis. MATERIALS AND METHODS CRAI was used as a new clinical technique to treat acute pancreatitis patients during a 4-year period at the First Affiliated Hospital, Wenzhou Medical College, China. In this retrospective study, thirty-four patients with proven infected pancreatic necrosis were included. Twelve patients were treated with CRAI, and were matched according to age, sex, APACHE II scores, Ranson scores and remote organ dysfunction, with 22 patients with IPN treated surgically. The clinical outcome following surgery and CRAI were compared. RESULTS No difference was found between the two groups when comparing age, gender, APACHE II scores, Ranson scores and remote organ dysfunction (p > 0.05). The patients treated with CRAI had a lower incidence of complications (33.3% vs 72.7%), duration of hospitalization (27.1 ± 4.7 days vs 43.0 ± 12.0 days) and cost of hospitalization (4.09 ± 1.64 thousand RMB vs 8.77 ± 3.74 thousand RMB) as compared to patients treated with surgery (p < 0.05). The survival rate was significantly higher in the CRAI group as compared to the surgical group (91.7% vs 63.6%; p < 0.01). However, the two groups had similar rates of concomitant operative treatment and incidence of remote organ dysfunction (p > 0.05). CONCLUSIONS CRAI or CRAI in combination with abscess drainage seemingly improve the clinical outcome in patients with infected pancreatic necrosis. Further confirmative prospective randomized multicenter studies are warranted prior to broad introduction of the CRAI concept.
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Affiliation(s)
- Mengtao Zhou
- Department of Surgery, The First Affiliated Hospital, Wenzhou Medical College, 2 Fuxue Lane, Wenzhou, Zhejiang Province, China.
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Ulagendra Perumal S, Pillai SA, Perumal S, Sathyanesan J, Palaniappan R. Outcome of video-assisted translumbar retroperitoneal necrosectomy and closed lavage for severe necrotizing pancreatitis. ANZ J Surg 2013; 84:270-4. [DOI: 10.1111/ans.12107] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2013] [Indexed: 12/26/2022]
Affiliation(s)
- Srinivasan Ulagendra Perumal
- Institute of Surgical Gastroenterology and Liver Transplantation; Government Stanley Medical College; Chennai India
| | - Sastha Ahanatha Pillai
- Institute of Surgical Gastroenterology and Liver Transplantation; Government Stanley Medical College; Chennai India
| | - Senthilkumar Perumal
- Institute of Surgical Gastroenterology and Liver Transplantation; Government Stanley Medical College; Chennai India
| | - Jeswanth Sathyanesan
- Institute of Surgical Gastroenterology and Liver Transplantation; Government Stanley Medical College; Chennai India
| | - Ravichandran Palaniappan
- Institute of Surgical Gastroenterology and Liver Transplantation; Government Stanley Medical College; Chennai India
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10
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Krishnan A, Ramakrishnan R. EUS-guided endoscopic necrosectomy and temporary cystogastrostomy for infected pancreatic necrosis with self-expanding metallic stents. Surg Laparosc Endosc Percutan Tech 2012; 22:e319-e321. [PMID: 23047418 DOI: 10.1097/sle.0b013e3182657e03] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pancreatic pseudocyst with infected necrotic tissue is associated with necrotizing pancreatitis and carries a high rate of complications and death. Open cystogastrostomy with removal of necrotic material and necrosectomy is the standard treatment for infected pancreatic necrosis but is associated with significant morbidity, mortality, and prolonged hospital stay. Endoscopic cyst drainage with necrosectomy is an alternative and less invasive technique. We report a case of endoscopic ultrasound-guided cystogastrostomy with a fully covered 15-mm-diameter self-expandable metal stent and staged endoscopic necrosectomy through the stent. This is the first case, so far, to use this technique with complete removal of necrotic material without any complications.
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Affiliation(s)
- Arunkumar Krishnan
- Department of Gastroenterology, Apollo Hospitals, Chennai, Tamil Nadu, India.
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Cruz-Santamaría DM, Taxonera C, Giner M. Update on pathogenesis and clinical management of acute pancreatitis. World J Gastrointest Pathophysiol 2012; 3:60-70. [PMID: 22737590 PMCID: PMC3382704 DOI: 10.4291/wjgp.v3.i3.60] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 05/22/2012] [Accepted: 06/12/2012] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP), defined as the acute nonbacterial inflammatory condition of the pancreas, is derived from the early activation of digestive enzymes found inside the acinar cells, with variable compromise of the gland itself, nearby tissues and other organs. So, it is an event that begins with pancreatic injury, elicits an acute inflammatory response, encompasses a variety of complications and generally resolves over time. Different conditions are known to induce this disorder, although the innermost mechanisms and how they act to develop the disease are still unknown. We summarize some well established aspects. A phase sequence has been proposed: etiology factors generate other conditions inside acinar cells that favor the AP development with some systemic events; genetic factors could be involved as susceptibility and modifying elements. AP is a disease with extremely different clinical expressions. Most patients suffer a mild and limited disease, but about one fifth of cases develop multi organ failure, accompanied by high mortality. This great variability in presentation, clinical course and complications has given rise to the confusion related to AP related terminology. However, consensus meetings have provided uniform definitions, including the severity of the illness. The clinical management is mainly based on the disease´s severity and must be directed to correct the underlying predisposing factors and control the inflammatory process itself. The first step is to determine if it is mild or severe. We review the principal aspects to be considered in this treatment, as reflected in several clinical practice guidelines. For the last 25 years, there has been a global increase in incidence of AP, along with many advances in diagnosis and treatment. However, progress in knowledge of its pathogenesis is scarce.
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12
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Deng ZG, Zhou JY, Yin ZY, Peng YY, Wang FQ, Wang XM. Continuous regional arterial infusion and laparotomic decompression for severe acute pancreatitis with abdominal compartment syndrome. World J Gastroenterol 2011; 17:4911-6. [PMID: 22171133 PMCID: PMC3235635 DOI: 10.3748/wjg.v17.i44.4911] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 06/11/2011] [Accepted: 07/11/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the therapeutic effects of abdominal decompression plus continuous regional arterial infusion (CRAI) via a drug delivery system (DDS) in severe acute pancreatitis (SAP) patients with abdominal compartment syndrome (ACS).
METHODS: We presented our recent experience in 8 patients with SAP. The patients developed clinical ACS, which required abdominal decompression. During the operation, a DDS was inserted into the peripancreatic artery (the catheter was inserted from the right gastroepiploic artery until it reached the junction between the pancreaticoduodenal and gastroduodenal artery). Through this DDS, a protease inhibitor, antibiotics and octreotide were infused continuously. The duration of the regional artery infusion ranged from 8 to 41 d. The outcomes and the changes in the APACHE II score, computed tomography (CT) severity index and intra-abdominal pressure (IAP) of the patients were retrospectively evaluated.
RESULTS: Eight patients with an initial APACHE IIscore of 18.9 (range, 13-27) and a Balthazar CT severity index of 9.1 (range, 7-10) developed severe local and systemic complications. These patients underwent subsequent surgical decompression and CRAI therapy because of intra-abdominal hypertension (IAH). After a mean interval of 131.9 ± 72.3 d hospitalization, 7 patients recovered with decreased APACHE II scores, CT severity indexes and IAP. The mean APACHE II score was 5.4 (range, 4-8), the CT severity index was 2.3 (range, 1-3), and IAP decreased to 7.7 mmHg (range, 6-11 mmHg) 60 d after operation. One patient died of multiple organ failure 1 wk after surgery.
CONCLUSION: CRAI and laparotomic decompression might be a therapeutic option for SAP patients with ACS.
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Kong H, Ding Z, Zhu XC, Gao XY, Wu J, Qian W, Wang CY, Hou XH. d-Dimer change in human acute pancreatitis as determined by serumal triglyceride. Pancreas 2011; 40:1103-1106. [PMID: 21926546 DOI: 10.1097/mpa.0b013e3182204ae3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of this present study was to investigate the d-dimer in acute pancreatitis and its associations with triglyceride (TG). METHODS The d-dimer was measured in 45 patients with mild acute pancreatitis, 43 patients with severe acute pancreatitis, and 45 healthy controls. Eighty-eight patients were divided into high and low TG groups based on their TG levels. Twenty outpatients with serumal TG levels higher than 5.65 mM were chosen as hypertriglyceridemia controls. We investigated whether there were any correlations between the d-dimer levels and serumal TG in acute pancreatitis. RESULTS In 45 patients with mild acute pancreatitis, the d-dimer increased to approximately 2 times over the reference value, whereas in 43 patients with severe acute pancreatitis, the d-dimer level increased to 6 times above the limit; the difference was significant. Both TG and acute pancreatitis could cause an elevation of the d-dimer level, in which TG takes a more important role. The increase in the d-dimer was also directly related to the severity of acute pancreatitis. CONCLUSIONS Plasma concentrations of the d-dimer increase in acute pancreatitis. The increase in TG is probably the main cause of the d-dimer elevation in patients with acute pancreatitis.
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Affiliation(s)
- Hao Kong
- Division of Gastroenterology, Union Hospital of Tongji Medical College, Wuhan, China
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14
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Jin HT, Lämsä T, Nordback PH, Hyvönen MT, Grigorenko N, Khomutov AR, Nordback I, Räty S, Pörsti I, Alhonen L, Sand J. Association between remote organ injury and tissue polyamine homeostasis in acute experimental pancreatitis – treatment with a polyamine analogue bismethylspermine. Pharmacol Rep 2011; 63:999-1008. [DOI: 10.1016/s1734-1140(11)70616-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Revised: 03/28/2011] [Indexed: 10/25/2022]
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15
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Ahmad HA, Samarasam I, Hamdorf JM. Minimally invasive retroperitoneal pancreatic necrosectomy. Pancreatology 2011; 11:52-6. [PMID: 21455014 DOI: 10.1159/000323960] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 12/01/2010] [Indexed: 12/11/2022]
Abstract
INTRODUCTION This article describes a case series outlining the experience and results of the retroperitoneal minimally invasive pancreatic necrosectomy (MIPN) procedure performed by, or done under the supervision of, a single surgeon. METHODS All data of the patients who underwent MIPN from 2006 to 2008 were entered into a prospectively maintained, computerized database. RESULTS A total of 93 MIPN procedures were performed on 32 patients. All patients had severe acute pancreatitis. The median number of MIPN procedures per patient was 3. Only 6 patients needed intensive care unit (ICU) admission after MIPN. There were 15 complications, which included bleeding requiring transfusion (n = 3), bowel fistulae (n = 7), thromboembolic events (n = 2) and acute myocardial infarction (n = 3). Four patients died after the procedure (13%); 1 died of ongoing multiorgan failure in spite of the MIPN. Four patients developed pancreatic pseudocysts within the follow-up period of 2 years. Three of these patients required intervention. CONCLUSION This case series demonstrates that MIPN can be performed with acceptable morbidity and mortality and with good end results. The ICU dependency after the procedure is minimal. As seen in this series, multiple MIPNs may be needed to eradicate the necrosis satisfactorily. and IAP.
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Affiliation(s)
- Hairul A Ahmad
- School of Surgery, The University of Western Australia, Perth, W.A., Australia.
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Abstract
The challenge for the pancreatologist managing patients with infected pancreatic necrosis is to devise a treatment algorithm that enables recovery but at the same time limits the morbidity and mortality. The current gold standard remains open necrosectomy. Recent literature contains scattered reports of endoscopic, radiologic, laparoscopic, percutaneous and lumbotomy approaches to managing patients with this condition. This literature review addresses the role of techniques that aim to minimize the physiological insult to the patient with infected pancreatic necrosis.
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Affiliation(s)
- A Peter Wysocki
- Department of Surgery, Logan Hospital, Meadowbrook, Queensland, Australia.
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Bacterial translocation and infected pancreatic necrosis in acute necrotizing pancreatitis derives from small bowel rather than from colon. Am J Surg 2010; 200:111-7. [PMID: 20637344 DOI: 10.1016/j.amjsurg.2009.08.019] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Revised: 08/02/2009] [Accepted: 08/04/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND The clinical course of acute necrotizing pancreatitis (ANP) is determined by the superinfection of pancreatic necrosis. To date, the pathophysiology of the underlying bacterial translocation is poorly understood. The present study investigated the bacterial source of translocation. METHODS A terminal loop ileostomy was applied in rats. Selective digestive decontamination (SDD) of either the small bowel or the colon was performed. After 3 days of SDD, severe ANP was induced. At 24 hours, bacterial translocation was assessed by cultures of bowel mucosa, mesenteric lymph nodes, and pancreas using a scoring system (0-4). RESULTS Without SDD, pancreatic infection was present in all cases with an average score of 2.67. Colon SDD reduced pancreatic superinfection to 1.67 (not significant). SDD of the small bowel significantly reduced superinfection to 1.0 (P < .005). CONCLUSIONS Bacterial translocation from the colon is less frequent than translocation from the small bowel. Thus, the small bowel seems to be the major source of enteral bacteria in infected pancreatic necrosis.
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Raraty MGT, Halloran CM, Dodd S, Ghaneh P, Connor S, Evans J, Sutton R, Neoptolemos JP. Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg 2010; 251:787-93. [PMID: 20395850 DOI: 10.1097/sla.0b013e3181d96c53] [Citation(s) in RCA: 193] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Comparison of minimal access retroperitoneal pancreatic necrosectomy (MARPN) versus open necrosectomy in the treatment of infected or nonresolving pancreatic necrosis. SUMMARY OF BACKGROUND DATA Infected pancreatic necrosis may lead to progressive organ failure and death. Minimal access techniques have been developed in an attempt to reduce the high mortality of open necrosectomy. METHODS This was a retrospective analysis on a prospective data base comprising 189 consecutive patients undergoing MARPN or open necrosectomy (August 1997 to September 2008). Outcome measures included total and postoperative ICU and hospital stays, organ dysfunction, complications and mortality using an intention to treat analysis. RESULTS Overall 137 patients underwent MARPN versus open necrosectomy in 52. Median (range) age of the patients was 57.5 (18-85) years; 118 (62%) were male. A total of 131 (69%) patients were tertiary referrals, with a median time to transfer from index hospital of 19 (2-76) days. Etiology was gallstones or alcohol in 129 cases (68%); 98 of 168 (58%) patients had a positive culture at the first procedure. Of the 137 patients, 34 (31%) had postoperative organ failure in the MARPN group, and 39 of 52 (56%) in the open group (P<0.0001); 59/137 (43%) versus 40/52 (77%), respectively, required postoperative ICU support (P<0.0001). Of the 137 patients 75 (55%) had complications in the MARPN group and 42 of 52 (81%) in the open group (P=0.001). There were 26 (19%) deaths in the MARPN group and 20 (38%) following open procedure (P=0.009). Age (P<0.0001), preoperative multiorgan failure (P<0.0001), and surgical procedure (MARPN, P=0.016) were independent predictors of mortality. CONCLUSION This study has shown significant benefits for a minimal access approach including fewer complications and deaths compared with open necrosectomy.
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Affiliation(s)
- Michael G T Raraty
- Pancreatic Biomedical Research Unit, Royal Liverpool and Broadgreen University Hospital NHS Trust and University of Liverpool, Liverpool, United Kingdom
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Minimally Invasive Retroperitoneal Pancreatic Necrosectomy in the Management of Infected Pancreatitis. Surg Laparosc Endosc Percutan Tech 2010; 20:e11-5. [DOI: 10.1097/sle.0b013e3181c8f340] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Zhang X, Chen L, Zhang J, Tian H, Zhang X, Zhou Y, Wang Z, Wang K. Effect of salvia miltiorrhizae on apoptosis and NF-kappaB p65 expression in the liver of rats with severe acute pancreatitis or obstructive jaundice. J Gastroenterol Hepatol 2009; 24:841-52. [PMID: 19067778 DOI: 10.1111/j.1440-1746.2008.05692.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To investigate the therapeutic effects and mechanism of salvia miltiorrhizae in the treatment of severe acute pancreatitis (SAP) or obstructive jaundice (OJ). METHODS SAP rat models were prepared and randomly divided into the model control group and treated group. The sham-operated group was also set. At 3 h, 6 h and 12 h after operation, the mortality rate, the pathological changes in the liver, the contents of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in serum, the expression levels of Bax and NF-kappaB p65 proteins in the liver, and the apoptosis index of hepatic cells in SAP rats in each group were observed. On days 7, 14, 21 and 28 after operation, the above parameters and the contents of TBILI (total billirubin), DBILI (direct bilirubin) and r-GT (r-glutamyl transpeptidase) in serum in OJ rats were observed. RESULTS The contents of serum ALT (at 6 h and 12 h after operation) and AST (at 3 h and 12 h after operation) as well as the staining intensity of NF-kappaB p65 protein (at 12 h after operation) in the liver of SAP rats in the treated group were significantly lower than those in model control group (all P < 0.01). The pathological severity scores (on 21 d and 28 d after operation) in the liver, the contents of serum ALT (on 14 d and 21 d after operation), AST (on 21 d after operation), TBILI (on 21 d and 28 d after operation), DBILI (on 28 d after operation) and r-GT (on 21 d after operation), and the apoptosis index of hepatic cells in OJ rats in treated group were significantly lower than those in model control group (all P < 0.05). The positive rates of Bax protein (on 28 d after operation) in treated group was significantly lower than model control group (P < 0.05). CONCLUSIONS Salvia miltiorrhizae is able to improve the liver function of SAP or OJ rats, suppress the expression of NF-kappaB p65 protein in the liver of SAP rats, and inhibit apoptosis in OJ rats, thereby showing some protective effects on the liver of SAP or OJ rats.
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Affiliation(s)
- Xiping Zhang
- Department of General Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.
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García-Barrasa A, Borobia FG, Pallares R, Jorba R, Poves I, Busquets J, Fabregat J. A double-blind, placebo-controlled trial of ciprofloxacin prophylaxis in patients with acute necrotizing pancreatitis. J Gastrointest Surg 2009; 13:768-74. [PMID: 19082671 DOI: 10.1007/s11605-008-0773-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Accepted: 11/24/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of prophylactic antibiotics in acute severe necrotizing pancreatitis is controversial. METHODS Prospective, randomized, placebo-controlled, double-blind study was carried out at Bellvitge Hospital, in Barcelona, Spain. Among 229 diagnosed with severe acute pancreatitis, 80 had evidence of necrotizing pancreatitis (34/80 patients were excluded of the protocol). Forty-six patients without previous antibiotic treatment with pancreatic necrosis in a contrast-enhanced CT scan were randomly assigned to receive either intravenous ciprofloxacin or placebo. Five patients were secondarily excluded, and the remaining 41 patients were finally included in the study (22 patients received intravenous ciprofloxacin and 19 patients placebo). RESULTS Comparing the 22 with intravenous ciprofloxacin and 19 with placebo, infected pancreatic necrosis was detected in 36% and 42% respectively (p = 0.7). The mortality rate was 18% and 11%, respectively (p = 0.6). No significant differences between both treatment groups were observed with respect to variables such as: non-pancreatic infections, surgical treatment, timing and the re-operation rate, organ failure, length of hospital and ICU stays. CONCLUSION The prophylactic use of ciprofloxacin in patients with severe necrotizing pancreatitis did not significantly reduce the risk of developing pancreatic infection or decrease the mortality rate. The small number of patients included in this study should be considered.
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Affiliation(s)
- A García-Barrasa
- Department of General Surgery and Digestive Tract, Bellvitge Hospital, Idibell, University of Barcelona, Barcelona, Spain
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The protecting effects and mechanisms of Baicalin and Octreotide on heart injury in rats with SAP. Mediators Inflamm 2008; 2007:19469. [PMID: 18274634 PMCID: PMC2220025 DOI: 10.1155/2007/19469] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2007] [Accepted: 10/24/2007] [Indexed: 12/13/2022] Open
Abstract
Purpose. To observe the protecting effects and mechanisms
of Baicalin and Octreotide on heart injury in rats with severe
acute pancreatitis (SAP).
Methods. The SAP rat models were randomly divided into
the model group, Baicalin-treated group, Octreotide treated group,
and sham operation group. The contents of some inflammatory
indexes in blood were determined. The rat mortality, pathological
changes of heart, the changes of NF-κB,
P-Selectin, Bax, Bcl-2, and Caspase-3 protein
expression levels as well as apoptotic index were observed in all
groups, respectively, at 3 hours, 6 hours, and 12 hours after
operation.
Results. The survival rate of model group was less
than treated groups at 12 hours, difference was significant. The
contents of some inflammatory indexes of the treated groups were
lower than those of the model group to various degrees at
different time points. The pathological myocardial changes under
light microscope were milder in treated groups than in model
group. The changes of
NF-κB,
P-Selectin, Bax, Bcl-2, and Caspase-3 protein expression levels in
all groups were different. There was only a case of myocardial
cell apoptosis in an Octreotide-treated group at 6 hours.
Conclusion. Baicalin and Octreotide have protecting
effects on heart injury of rats with SAP.
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Dang SC, Zhang JX, Qu JG, Mao ZF, Wang XQ, Zhu B. Dynamic changes of IL-2/IL-10, sFas and expression of Fas in intestinal mucosa in rats with acute necrotizing pancreatitis. World J Gastroenterol 2008; 14:2246-50. [PMID: 18407603 PMCID: PMC2703854 DOI: 10.3748/wjg.14.2246] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate dynamic changes of serum IL-2, IL-10, IL-2/IL-10 and sFas in rats with acute necrotizing pancreatitis. To explore the expression of Fas in intestinal mucosa of rats with acute necrotizing pancreatitis (ANP).
METHODS: A total of 64 Sprague-Dawley (SD) rats were randomly divided into two groups: normal control group (C group), ANP group (P group). An ANP model was induced by injection of 50 g/L sodium taurocholate under the pancreatic membrane. Normal control group received isovolumetric injection of 9 g/L physiological saline solution using the same method. The blood samples of the rats in each group were obtained via superior mesenteric vein to measure levels of IL-2, IL-10, sFas and calculate the value of IL-2/IL-10. The levels of IL-2, IL-10 and sFas were determined by ELISA. The severity of intestinal mucosal injury was evaluated by pathologic score. The expression of Fas in intestinal mucosal tissue was determined by immunohistochemistry staining.
RESULTS: Levels of serum IL-2 were significantly higher in P group than those of C group (2.79 ± 0.51 vs 3.53 ± 0.62, 2.93 ± 0.89 vs 4.35 ± 1.11, 4.81 ± 1.23 vs 6.94 ± 1.55 and 3.41 ± 0.72 vs 4.80 ± 1.10, respectively, P < 0.01, for all) and its reached peak at 6 h. Levels of serum IL-10 were significantly higher in P group than those of C group at 6 h and 12 h (54.61 ± 15.81 vs 47.34 ± 14.62, 141.15 ± 40.21 vs 156.12 ± 43.10, 89.18 ± 32.52 vs 494.98 ± 11.23 and 77.15 ± 22.60 vs 93.28 ± 25.81, respectively, P < 0.01, for all). The values of IL-2/IL-10 were higher significantly in P group than those of C group at 0.5 h and 2 h (0.05 ± 0.01 vs 0.07 ± 0.02 and 0.02 ± 0.01 vs 0.03 ± 0.01, respectively, P < 0.01, for all), and it were significantly lower than those of C group at 6 h (0.05 ± 0.02 vs 0.01 ± 0.01, P < 0.01) and returned to the control level at 12 h (0.04 ± 0.01 vs 0.05 ± 0.02, P > 0.05). In sFas assay, there was no significant difference between P group and C group (3.16 ± 0.75 vs 3.31 ± 0.80, 4.05 ± 1.08 vs 4.32 ± 1.11, 5.93 ± 1.52 vs 5.41 ± 1.47 and 4.62 ± 1.23 vs 4.44 ± 1.16, respectively, P > 0.05, for all). Comparison of P group and C group, the pathological changes were aggravated significantly in P group. Immunohistochemistry staining show the expression of Fas was absent in normal intestinal tissues, however, it gradually increased after induction of pancreatitis in intestinal tissue, then reached their peaks at 12 h.
CONCLUSION: Fas were involved in the pathogenesis of pancreatitis associated intestinal injury. The mechanisms of Fas may be associated to Fas mediated T helper cell apoptosis.
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Clostridium septicum Infection Associated with Necrotizing Pancreatitis, Transmural Gastric Necrosis, and Liquefaction of the Spleen. Eur J Trauma Emerg Surg 2008; 34:77-9. [PMID: 26815495 DOI: 10.1007/s00068-007-7084-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Accepted: 09/18/2007] [Indexed: 10/22/2022]
Abstract
Spontaneous infection with Clostridium septicum (C. septicum) is rare, but when isolated it is commonly associated with malignancy. We report a case of a 47-year-old man with infected pancreatic necrosis involving greater than 80% of the pancreas, transmural gastric necrosis, and liquefaction necrosis of the spleen. Initial cultures revealed C. septicum infection. He was managed with prompt aggressive surgical debridément, resection, appropriate broad spectrum antibiotics, and early enteral nutrition.
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Zhang XP, Wang L, Zhou YF. The pathogenic mechanism of severe acute pancreatitis complicated with renal injury: a review of current knowledge. Dig Dis Sci 2008; 53:297-306. [PMID: 17597411 DOI: 10.1007/s10620-007-9866-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2006] [Accepted: 06/04/2006] [Indexed: 01/30/2023]
Abstract
The onset of severe acute pancreatitis (SAP) is clinically harmful as it may rapidly progress from a local pancreatic inflammation into proemial systemic inflammatory reactions. Patients with SAP have a high mortality, with most cases of death resulting from complications involving the failure of organs other than the pancreas. The distinctive feature of SAP is that once it starts, it may aggrevate the clinical condition of the patient continuously, so that the levels of injury to the other organs surpass the severity of the pancreatic lesion, even causing multiple organ failure and, ultimately, death. In clinical practice, the main complications in terms of organ dysfunctions are shock, acute respiratory failure, acute renal failure, among others. The acute renal injury caused by SAP is not only able to aggravate the state of pancreatitis, but it also develops into renal failure and elevates patients' mortality. Studies have found that the injury due to massive inflammatory mediators, microcirculation changes and apoptosis, among others, may play important roles in the pathogenic mechanism of acute renal injury.
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Affiliation(s)
- Xi Ping Zhang
- Department of General Surgery, Hangzhou First People's Hospital, Hangzhou, Zhejiang Province 310006, China.
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Yasuda T, Ueda T, Takeyama Y, Shinzeki M, Sawa H, Nakajima T, Matsumoto I, Fujita T, Sakai T, Ajiki T, Fujino Y, Kuroda Y. Treatment strategy against infection: clinical outcome of continuous regional arterial infusion, enteral nutrition, and surgery in severe acute pancreatitis. J Gastroenterol 2007; 42:681-9. [PMID: 17701132 DOI: 10.1007/s00535-007-2081-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Accepted: 06/02/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND In severe acute pancreatitis (SAP), infectious complications are the main contributors to high mortality. Since 1995, we have performed continuous regional arterial infusion of protease inhibitor and antibiotics (CRAI) and enteral nutrition (EN) as prevention therapies against infection. When infected pancreatic necrosis was proven, surgical intervention was adapted. The aim of this study was to investigate the clinical outcome of these treatments. METHODS We examined the relationship between the historical change of treatment strategy and clinical outcome. We divided 84 patients with acute necrotizing pancreatitis into two groups, CRAI (-) and CRAI (+), and compared the outcome. We divided 145 patients with SAP into two groups, EN (-) and EN (+), and compared the outcome. We also analyzed the outcome of surgical treatment. RESULTS In the CRAI (+) group, the incidence of infection, the frequency of surgery, and the mortality rate were lower than those in CRAI (-) group: 34% versus 51%, 27% versus 63% (P < 0.05), and 37% versus 54%, respectively. In the EN (+) group, the frequency of surgery and the mortality rate were lower than those in the EN (-) group: 23% versus 32% and 19% versus 35% (P < 0.05), respectively. These improvement effects were manifest in stage 3 (9 < or = Japanese Severity Score < or = 14). Treatment outcome of necrosectomy for infected pancreatic necrosis was still poor. Bleeding and abscess-gut fistula were postoperative life-threatening complications. CONCLUSIONS CRAI and EN may improve the clinical outcome of SAP, reducing infection and averting pancreatic surgery.
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Affiliation(s)
- Takeo Yasuda
- Department of Gastroenterological Surgery, Kobe University Graduate School of Medical Sciences, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
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Zhang XP, Wang L, Zhang J. Study progress on mechanism of severe acute pancreatitis complicated with hepatic injury. J Zhejiang Univ Sci B 2007; 8:228-36. [PMID: 17444596 PMCID: PMC1838834 DOI: 10.1631/jzus.2007.b0228] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Study on the action mechanism of inflammatory mediators generated by the severe acute pancreatitis (SAP) in multiple organ injury is a hotspot in the surgical field. In clinical practice, the main complicated organ dysfunctions are shock, respiratory failure, renal failure, encephalopathy, with the rate of hepatic diseases being closely next to them. The hepatic injury caused by SAP cannot only aggravate the state of pancreatitis, but also develop into hepatic failure and cause patient death. Its complicated pathogenic mechanism is an obstacle in clinical treatment. Among many pathogenic factors, the changes of vasoactive substances, participation of inflammatory mediators as well as OFR (oxygen free radical), endotoxin, etc. may play important roles in its progression.
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Affiliation(s)
- Xi-ping Zhang
- Department of General Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China.
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Kaya E, Dervisoglu A, Polat C. Evaluation of diagnostic findings and scoring systems in outcome prediction in acute pancreatitis. World J Gastroenterol 2007; 13:3090-4. [PMID: 17589925 PMCID: PMC4172616 DOI: 10.3748/wjg.v13.i22.3090] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine factors related to disease severity, mortality and morbidity in acute pancreatitis.
METHODS: One hundred and ninety-nine consecutive patients were admitted with the diagnosis of acute pancreatitis (AP) in a 5-year period (1998-2002). In a prospective design, demographic data, etiology, mean hospital admission time, clinical, radiological, biochemical findings, treatment modalities, mortality and morbidity were recorded. Endocrine insufficiency was investigated with oral glucose tolerance test. The relations between these parameters, scoring systems (Ranson, Imrie and APACHE II) and patients’ outcome were determined by using invariable tests and the receiver operating characteristics curve.
RESULTS: One hundred patients were men and 99 were women; the mean age was 55 years. Biliary pancreatitis was the most common form, followed by idiopathic pancreatitis (53% and 26%, respectively). Sixty-three patients had severe pancreatitis and 136 had mild disease. Respiratory rate > 20/min, pulse rate > 90/min, increased C-reactive protein (CRP), lactate dehydrogenase (LDH) and aspartate aminotransferase (AST) levels, organ necrosis > 30% on computed tomography (CT) and leukocytosis were associated with severe disease. The rate of glucose intolerance, morbidity and mortality were 24.1%, 24.8% and 13.6%, respectively. CRP > 142 mg/L, BUN > 22 mg/dL, LDH > 667 U/L, base excess > -5, CT severity index > 3 and APACHE score > 8 were related to morbidity and mortality.
CONCLUSION: APACHE II score, LDH, base excess and CT severity index have prognostic value and CRP is a reliable marker for predicting both mortality and morbidity.
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Affiliation(s)
- Ekrem Kaya
- Ondokuz Mayis University School of Medicine Department of Surgery, Samsun, Turkey.
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Røkke O, Harbitz TB, Liljedal J, Pettersen T, Fetvedt T, Heen LØ, Skreden K, Viste A. Early treatment of severe pancreatitis with imipenem: a prospective randomized clinical trial. Scand J Gastroenterol 2007; 42:771-6. [PMID: 17506001 DOI: 10.1080/00365520601173855] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The main causes of death in severe pancreatitis are multiorgan failure and septic complications. Prophylactic treatment with effective antibiotics is therefore a tempting therapeutic option. However, there could be side effects such as selection of resistant microbes and fungi. The aim of the present study was to compare the rate of infectious complications, interventions, days in the intensive care unit (ICU), morbidity and mortality in patients with severe pancreatitis randomized to prophylactic therapy with imipenem compared with those receiving no treatment at all. MATERIAL AND METHODS Seventy-three patients with severe pancreatitis were included in a prospective, randomized, clinical study in seven Norwegian hospitals. The number of patients was limited to 73 because of slow patient accrual. Severe pancreatitis was defined as a C-reactive protein (CRP) level of >120 mg/l after 24 h or CRP >200 48 h after the start of symptoms. The patients were randomized to either early antibiotic treatment (imipenem 0.5 g x 3 for 5-7 days) (imipenem group) (n=36) or no antibiotics (control group) (n=37). RESULTS The groups were similar in age, cause of pancreatitis, duration of symptoms and APACHE II score. Patients in the imipenem group experienced lower rates of complications (12 versus 22 patients) (p=0.035) and infections (5 versus 16 patients) (p=0.009) than those in the control group. There was no difference in length of hospital stay (18 versus 22 days), need of intensive care (8 versus 7 patients), need of acute interventions (10 versus 13), nor for surgery (3 versus 3) or 30-day mortality rates (3 versus 4). CONCLUSIONS The study, although underpowered, supports the use of early prophylactic treatment with imipenem in order to reduce the rate of septic complications in patients with severe pancreatitis.
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Affiliation(s)
- Ola Røkke
- Department of Surgery, Haukeland University Hospital, Norway.
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Lee JK, Kwak KK, Park JK, Yoon WJ, Lee SH, Ryu JK, Kim YT, Yoon YB. The efficacy of nonsurgical treatment of infected pancreatic necrosis. Pancreas 2007; 34:399-404. [PMID: 17446837 DOI: 10.1097/mpa.0b013e318043c0b1] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES We conducted this study to evaluate the efficacy of nonsurgical treatment for patients with infected pancreatic necrosis (IPN). METHODS Among 224 patients with acute pancreatitis from 2000 to 2004, there were 31 patients diagnosed as having IPN complication. The diagnostic criteria for IPN were either a positive culture or free gas in the pancreas of patients with acute pancreatic necrosis. Nonsurgical management including percutaneous drainage or endoscopic drainage (ED) followed by vigorous irrigation was initially attempted in all patients. Surgery was planned only when there was no clinical improvement after the initial nonsurgical treatment. RESULTS Percutaneous drainage or ED was performed in 18 and 5 patients, respectively. Eight patients received antibiotics only. Four patients (12.9%) (3 from percutaneous drainage group and 1 from ED group) required surgery. Sepsis or fistula developed in 32% and 6% of patients, respectively, and was managed successfully. One patient (3.2%) died as a result of rapidly progressing multiorgan failure. The mean duration of hospitalization was 37 days. During the follow-up period, 7 patients were readmitted because of fever; they were managed by reposition of the drainage tube. CONCLUSIONS Intensive nonsurgical treatment is very effective and safe and should be considered as an initial treatment modality for patients with IPN.
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Affiliation(s)
- Jun Kyu Lee
- Department of Internal Medicine, Dongguk University International Hospital, Dongguk University College of Medicine, Goyang, Korea
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Eckerwall GE, Axelsson JB, Andersson RG. Early nasogastric feeding in predicted severe acute pancreatitis: A clinical, randomized study. Ann Surg 2006; 244:959-967. [PMID: 17122621 PMCID: PMC1856625 DOI: 10.1097/01.sla.0000246866.01930.58] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of early, nasogastric enteral nutrition (EN) with total parenteral nutrition (TPN) in patients with predicted severe acute pancreatitis (SAP). SUMMARY BACKGROUND DATA In SAP, the magnitude of the inflammatory response as well as increased intestinal permeability correlates with outcome. Enteral feeding has been suggested superior to parenteral feeding due to a proposed beneficial effect on the gut barrier. METHODS Fifty patients who met the inclusion criteria were randomized to TPN or EN groups. The nutritional regimen was started within 24 hours from admission and EN was provided through a nasogastric tube. The observation period was 10 days. Intestinal permeability was measured by excretion of polyethylene glycol (PEG) and concentrations of antiendotoxin core antibodies (Endocab). Interleukins (IL)-6 IL-8, and C-reactive protein (CRP) were used as markers of the systemic inflammatory response. Morbidity and feasibility of the nutritional route were evaluated by the frequency of complications, gastrointestinal symptoms, and abdominal pain. RESULTS PEG, Endocab, CRP, IL-6, APACHE II score, severity according to the Atlanta classification (22 patients), and gastrointestinal symptoms or abdominal pain did not significantly differ between the groups. The incidence of hyperglycemia was significantly higher in TPN patients (21 of 26 vs. 7 of 23; P < 0.001). Total complications (25 vs. 52; P = 0.04) and pulmonary complications (10 vs. 21; P = 0.04) were significantly more frequent in EN patients, although complications were diagnosed dominantly within the first 3 days. CONCLUSION In predicted SAP, nasogastric early EN was feasible and resulted in better control of blood glucose levels, although the overall early complication rate was higher in the EN group. No beneficial effects on intestinal permeability or the inflammatory response were seen by EN treatment.
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Navalho M, Pires F, Duarte A, Gonçalves A, Alexandrino P, Távora I. Percutaneous drainage of infected pancreatic fluid collections in critically ill patients: correlation with C-reactive protein values. Clin Imaging 2006; 30:114-9. [PMID: 16500542 DOI: 10.1016/j.clinimag.2005.09.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2005] [Revised: 09/07/2005] [Accepted: 09/07/2005] [Indexed: 01/27/2023]
Abstract
The objective of this study was to assess the efficacy of percutaneous catheter drainage, of early infected pancreatic fluid collections, in critically ill patients with severe acute pancreatitis. The patients in our series had a mean Ranson's score of 5.4. Nineteen (63.3%) of the 30 patients were cured with percutaneous drainage. In this group, the mean C-reactive protein value at the beginning of treatment was 172.8 U/l and 102.5 U/l at the end (P<.001). Cultures yielded multiple organisms in 23 patients (76.7%). The most frequently seen organisms were Escherichia coli, Staphylococcus aureus, and Enterococcus faecium.
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Affiliation(s)
- Márcio Navalho
- Radiology Department, University Hospital of Santa Maria, Avenida Professor Egas Moniz, 1649-035 Lisbon, Portugal.
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Lin JC, Hou SJ, Huang LU, Sun JR, Chang WK, Lu JJ. Acute cholecystitis accompanied by acute pancreatitis potentially caused by Dolosigranulum pigrum. J Clin Microbiol 2006; 44:2298-9. [PMID: 16757645 PMCID: PMC1489456 DOI: 10.1128/jcm.02520-05] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We report a case of acute cholecystitis accompanied by acute pancreatitis and caused by Dolosigranulum pigrum in a 76-year-old male with gallstones. D. pigrum was isolated from a blood culture and confirmed by biochemistry tests and 16S rRNA sequencing. The isolate was susceptible to the beta-lactams ampicillin, penicillin, cephalothin, ceftriaxone, ceftazidime, chloramphenicol, and vancomycin but was intermediate to erythromycin and clindamycin. The patient recovered without sequelae after treatment with appropriate antibiotics for two weeks.
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Affiliation(s)
- Jung-Chung Lin
- Division of Infectious Diseases and Tropical Medicine, Tri-Service General Hospital, National Defence Medical Center, Taipei, Taiwan, Republic of China
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Connor S, Raraty MGT, Neoptolemos JP, Layer P, Rünzi M, Steinberg WM, Barkin JS, Bradley EL, Dimagno E. Does infected pancreatic necrosis require immediate or emergency debridement? Pancreas 2006; 33:128-34. [PMID: 16868477 DOI: 10.1097/01.mpa.0000234074.76501.a6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Saxon Connor
- Division of Surgery and Oncology, University of Liverpool, Royal Liverpool University Hospital, Liverpool, United Kingdom
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Connor S, Raraty MGT, Howes N, Evans J, Ghaneh P, Sutton R, Neoptolemos JP. Surgery in the treatment of acute pancreatitis--minimal access pancreatic necrosectomy. Scand J Surg 2005; 94:135-42. [PMID: 16111096 DOI: 10.1177/145749690509400210] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Between 5% and 10% of patients with acute pancreatitis will develop infected pancreatic necrosis. Traditional open surgery for this condition carries a mortality rate of up to 50%, and therefore a number of less invasive techniques have been developed, including radiological drainage and a minimal access retroperitoneal approach. No randomised controlled trials have been published which compare these techniques. Indications for minimal access surgery are the same as for open surgery, i.e. infected pancreatic necrosis or failure to improve with extensive sterile necrosis. Access is obtained to the pancreatic necrosis via the left loin and necrosectomy performed using an operating nephroscope, and this often requires several procedures to remove all necrotic tissue. The cavity is continuously irrigated on the ward in between procedures. The results of this approach are encouraging, with less systemic upset to the patient, a lower incidence of post-operative organ failure when compared with open surgery, and a reduced requirement for ITU support. There is also a trend towards a lower mortality rate, although this does not reach statistical significance on the data published so far. Current evidence suggests that a minimal access approach to pancreatic necrosis is feasible, well tolerated and beneficial for the patient when compared with open surgery.
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Affiliation(s)
- S Connor
- Division of Surgery and Oncology, University of Liverpool, Liverpool, UK
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Watanabe J, Kushihata F, Honda K, Kobayashi N. The usefulness of early laparoscopic surgery for determining a medical treatment plan in severe acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2005; 12:422-5. [PMID: 16258814 DOI: 10.1007/s00534-005-1007-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2005] [Accepted: 05/09/2005] [Indexed: 10/25/2022]
Abstract
A 41-year-old woman presented with sudden onset severe epigastric pain. She was diagnosed as having severe acute pancreatitis (SAP) with an APACHE II score of 10, and initially, general supportive therapy was performed. Because the patient's condition kept worsening, early laparoscopic surgery was performed. It revealed swelling, hemorrhagic necrosis of the pancreas, and massive fluid collection in the abdominal cavity. Kocherization and bursectomy were performed for these lesions, and drainage tubes were indwelled. The white blood cell count (WBC) and serum interleukin-6 value prominently improved shortly after the operation, and the WBC count remained at a low level. The patient gradually recovered and was finally discharged 39 days after her initial presentation. To summarize, we performed a successful exploration for SAP, and we found that postoperative continuous lavage effectively eliminated toxic enzymatic exudates in the abdominal cavity and prevent them from circulating. Regarding SAP with peritonitis, early laparoscopic surgery is very useful for determining the pathological extent of the disease and for selecting appropriate treatment options.
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Affiliation(s)
- Jota Watanabe
- First Department of Surgery, Ehime University School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
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N/A, 王 蕾. N/A. Shijie Huaren Xiaohua Zazhi 2005; 13:2364-2370. [DOI: 10.11569/wcjd.v13.i19.2364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Maraví Poma E, Jiménez Urra I, Gener Raxarch J, Zubia Olascoaga F, Pérez Mateo M, Casas Curto J, Montejo González J, García de Lorenzo A, López Camps V, Fernández Mondéjar E, Álvarez Lerma F, Vallés Daunis J, Olaechea Astigarraga P, Domínguez Muñoz E, Tellado Rodríguez J, Landa García I, Lafuente Martínez J, Villalba Martín C, Sesma Sánchez J. Recomendaciones de la 7ª Conferencia de Consenso de la SEMICYUC. Pancreatitis aguda grave en Medicina Intensiva. Med Intensiva 2005. [DOI: 10.1016/s0210-5691(05)74245-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Connor S, Alexakis N, Raraty MGT, Ghaneh P, Evans J, Hughes M, Garvey CJ, Sutton R, Neoptolemos JP. Early and late complications after pancreatic necrosectomy. Surgery 2005; 137:499-505. [PMID: 15855920 DOI: 10.1016/j.surg.2005.01.003] [Citation(s) in RCA: 206] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgery for pancreatic necrosis is associated with a high morbidity and mortality. The aim of this study was to review the incidence of early and late complications after pancreatic necrosectomy in a large contemporary series of patients. METHODS The clinical outcomes of 88 patients who underwent pancreatic necrosectomy between 1997 and 2003 were reviewed. RESULTS The median age was 55.5 (range, 18-85) years, 54 (61%) were males, 68 (77%) had primary pancreatic infection, 71 (81%) had >50% necrosis, and the median admission Acute Physiology and Chronic Health Evaluation score was 9 (range, 1-21). Median time to surgery was 31 (range, 1-161) days; 47 patients underwent minimally invasive necrosectomy and 41 open necrosectomy; 81 (92%) of patients had complications postoperatively, and 25 (28%) died. Multiorgan failure (odds ratio = 3.4, P = .05) and hemorrhage (odds ratio = 6.1, P = .03) were the only independent predictors of mortality. During a median follow-up of 28.9 months, 39 (62%) of 63 surviving patients had one or more late complications: biliary stricture in 4 (6%), pseudocyst in 5 (8%), pancreatic fistula in 8 (13%), gastrointestinal fistula in 1 (2%), delayed collections in 3 (5%), and incisional hernia in 1 (2%); intervention was required in 10 (16%) patients. Sixteen (25%) of 63 surviving patients developed exocrine insufficiency, and 19 (33%) of 58 without prior diabetes mellitus developed endocrine insufficiency. CONCLUSIONS Almost all patients undergoing necrosectomy developed significant early or late complications or both. Multiorgan failure and postoperative hemorrhage were independent predictors of mortality. Long-term follow-up was important because 62% developed complications, and 16% of those with complications required surgical or endoscopic intervention.
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Affiliation(s)
- S Connor
- Department of Surgery, Royal Liverpool University Hospital
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Kujath P, Rosenfeldt M, Esnaashari H, Scheele J, Bouchard R. Pilzinfektion bei hamorrhagisch-nekrotisierender Pankreatitis: Risikofaktoren, Inzidenz, Therapie. Fungal infections in patients with necrotizing pancreatitis: risk-factors, incidence, therapy. Mycoses 2005; 48 Suppl 1:36-40. [PMID: 15826285 DOI: 10.1111/j.1439-0507.2005.01108.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Haemorraghic necrotizing pancreatitis may lead to a serious disease with multi-organ failure, which is to be treated with intensive care. Patients suffering from infected necrosis are usually operated (necrosectomy). By doing this, it is possible to get a microbiological analysis. The most common virulent species are Enterobacteriaceae. According to the literature, fungal infections appear in 15-30% of the cases. Since 1996, 73 patients were treated surgically in our department. A number of 50 patients (68,5%) developed a fungal infection during the course of the disease. The mortality rate was 62%.
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Affiliation(s)
- P Kujath
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, D-23538 Lübeck, Germany.
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Mishra G, Pineau BC. Infectious complications of pancreatitis: diagnosis and management. Curr Gastroenterol Rep 2004; 6:280-6. [PMID: 15245695 DOI: 10.1007/s11894-004-0079-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Infected pancreatic necrosis is the leading cause of death in patients with severe acute pancreatitis. Early prophylactic antibiotic treatment is effective in preventing conversion of sterile necrosis to pancreatic infection, but its effect on mortality remains unproven. Fungal infections may predict a worse outcome, but no evidence supports the use of antifungal prophylaxis. Because infection of pancreatic necrosis by enteric bacteria can develop despite prophylaxis, a high index of suspicion should allow early detection followed by aggressive management.
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Affiliation(s)
- Girish Mishra
- Department of Internal Medicine, Section of Gastroenterology, Wake Forest University School of Medicine, 3rd Floor North Tower, 2 Medical Center Boulevard, Winston-Salem, NC 27157, USA
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Wen QP, Chen HL, Guan FL. Effect of Qingyitang on acute lung injury induced by severe acute pancreatitis in rats. Shijie Huaren Xiaohua Zazhi 2004; 12:1341-1345. [DOI: 10.11569/wcjd.v12.i6.1341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the treatment of different Chinese medicines in rats with acute lung injury (ALI) induced by severe acute pancreatitis (SAP).
METHODS: 15 g/L sodium deoxycholate was injected inversely into the common biliopancreatic duct in rat to make the model of ALI during SAP. The rats were devided into 6 groups randomly: sham operated controls (n = 10), SAP model (n = 20), SAP+Sandostatin (n = 10), SAP+ Dexamethasoni (n = 10), SAP + Kefadim (n = 10), and SAP +Qingyitang (n = 10). All the rats were killed 24 hours after operation and treatment. The levels of TNF, IL-6, MDA, SOD, and NO in serum and pulmonary homogenate were measured.
RESULTS: The levels of ET, TNF, IL-6, SOD, and MDA in serum and pulmonary homogenate in the model group were significantly higher than those of sham operated control group (P < 0.01). The indexes of blood gas analysis showed obvious pathological changes in the model group and so did the pathological examination of lung tissue. The indexes of ALI-SAP + Qingyitang group were better than those of the model group (P < 0.05). The effect of sandostatin on suppressing serum amylase was most significant. Dexamethasoni was effective on the amelioration of blood gas and W/T.
CONCLUSION: ET, TNF, IL-6, and OFR play an important role in ALI caused by SAP. Qingyitang protects lung from injury in many aspects, preserving the gut barrier function, reducing or eliminate endotoxemia derived from the gut, and inhibiting the production and release of TNF, IL-6 and the translocation of bacteria. Dexamethasoni, sandostatin, kefadim have certain effect on reducing the levels of some indexes respectively, but those treatments can not improve the death rate. Qingyitang is superior to other methods.
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Raraty MGT, Connor S, Criddle DN, Sutton R, Neoptolemos JP. Acute pancreatitis and organ failure: pathophysiology, natural history, and management strategies. Curr Gastroenterol Rep 2004; 6:99-103. [PMID: 15191686 DOI: 10.1007/s11894-004-0035-0] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Acute pancreatitis is a common condition that carries a significant risk of morbidity and mortality. It is characterized by intra-acinar cell activation of digestive enzymes and a subsequent systemic inflammatory response governed by the release of proinflammatory cytokines. In 80% of patients the disease runs a self-limiting course, but in the rest, pancreatic necrosis and systemic organ failure carry a mortality rate of up to 40%. The key to management is early identification of the patients liable to have a severe attack and require treatment in a high-dependency or critical-care setting by a specialist team. In gallstone-induced pancreatitis, early removal of ductal calculi by endoscopic sphincterotomy is indicated. The use of prophylactic antibiotics to prevent the infection of pancreatic necrosis remains controversial, but once established, infected necrosis must be removed. Although a number of techniques to accomplish this end have been described, minimally invasive techniques are gaining in popularity.
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Affiliation(s)
- Michael G T Raraty
- Department of Surgery, University of Liverpool, 5th Floor, UCD Building, Royal Liverpool University Hospital, Daulby Street, Liverpool L69 3GA, UK
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Harris HW, Barcia A, Schell MT, Thoeni RF, Schecter WP. Necrotizing pancreatitis: a surgical approach independent of documented infection. HPB (Oxford) 2004; 6:161-8. [PMID: 18333070 PMCID: PMC2020671 DOI: 10.1080/13651820410033634] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Strategies for the management of patients with necrotizing pancreatitis remain controversial. While consensus opinion supports operative necrosectomy for the treatment of infected pancreatic necrosis, the timing for surgical intervention is not completely resolved. Further, the indication for the surgical management of sterile pancreatic necrosis is also subject to debate. METHODS The objective of this study was to evaluate outcome measures for the surgical management of necrotizing pancreatitis, independent of documented infection. A retrospective review was undertaken between 1994 and 2002 at a single county hospital. RESULTS Twenty-one patients with CT-documented necrotizing pancreatitis underwent operative pancreatic necrosectomy with laparostomy within 21 days of initial diagnosis and had an average of three reoperations. Average length of stay (LOS) in the ICU was 36 days and in the hospital 67 days. Ten patients had documented infected necrosis based on initial intra-operative cultures, while I I had sterile necrosis. Overall, 95% (20/21) of the patients had a complication, with an average of three complications per patient. Common complications included ARDS (71%), sepsis (33%), renal failure (24%), and pneumonia (24%). The overall mortality rate was 14% (3/21), with a mean follow-up of 469 days. DISCUSSION The surgical management of acute necrotizing pancreatitis, independent of documented infection, can be undertaken within 3 weeks of diagnosis with an acceptable morbidity and a low mortality rate. Creation of a laparostomy to enable ready, atraumatic debridement of the retroperitoneum is a safe alternative to standard repeat laparotomies and thus represents a useful adjunct to the surgical management of necrotizing pancreatitis.
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Affiliation(s)
- HW Harris
- Department of Surgery, University of CaliforniaSan Francisco CAUSA
| | - A Barcia
- Department of Surgery, University of CaliforniaSan Francisco CAUSA
| | - MT Schell
- Department of Surgery, University of CaliforniaSan Francisco CAUSA
| | - RF Thoeni
- Department of Radiology, University of CaliforniaSan Francisco CAUSA
| | - WP Schecter
- Department of Surgery, University of CaliforniaSan Francisco CAUSA
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Maraví-Poma E, Gener J, Alvarez-Lerma F, Olaechea P, Blanco A, Domínguez-Muñoz JE. Early antibiotic treatment (prophylaxis) of septic complications in severe acute necrotizing pancreatitis: a prospective, randomized, multicenter study comparing two regimens with imipenem-cilastatin. Intensive Care Med 2003; 29:1974-80. [PMID: 14551680 DOI: 10.1007/s00134-003-1956-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2002] [Accepted: 05/05/2003] [Indexed: 01/28/2023]
Abstract
OBJECTIVE We compared two imipenem regimens for prevention of septic complications in patients with severe acute necrotizing pancreatitis (ANP). DESIGN AND SETTING Prospective, randomized open clinical trial involving intensive care units of 14 Spanish Hospitals. PARTICIPANTS 92 patients with ANP. INTERVENTIONS Imipenem/cilastatin was administered at 500 mg four times daily starting at the time of diagnosis of ANP, within the first 96 h from the onset of symptoms. Patients were randomized to receive antibiotic prophylaxis either for 14 days (group 1) or at least for 14 days and as long as major systemic complications of the disease persisted (group 2). RESULTS Antibiotic was maintained in group 2 for 19.7+/-10.9 days. The incidence of infected pancreatic necrosis, pancreatic abscess, and extrapancreatic infections was 11%, 17%, and 28% in group 1 and 17.4%, 13%, and 35% in group 2 (n.s.). Pancreatic or extrapancreatic infection by Candida albicans occurred in 7% and 22% of patients. Global mortality was 18.5% (10.9% secondary to septic complications), without differences between groups. In patients with persisting systemic complications at day 14 mortality was almost always secondary to septic complications and decreased from 25% (group 1) to 8.8% (group 2) by maintaining antibiotic prophylaxis. CONCLUSIONS Compared to a 14-day imipenem prophylaxis, a longer antibiotic administration in patients with ANP is not associated with a reduction in the incidence of septic complications of the disease. However, prolonged imipenem administration in patients with persisting systemic complications tends to reduce mortality in ANP compared to a 14-days regimen.
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Affiliation(s)
- Enrique Maraví-Poma
- ICU, Servicio Navarro de Salud-Osasunbidea, Hospital Virgen del Camino, Irunlarrea 4, 31002, Pamplona, Spain.
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Sun W, Zhang JD, Zhao Y, Zhao Y, Wang Q. Expression of IL-6 and integrin family cell adhesion molecules in acute necrotizing pancreatitis complicated with multiple organ injury in rats. Shijie Huaren Xiaohua Zazhi 2003; 11:753-755. [DOI: 10.11569/wcjd.v11.i6.753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To detect the expression of integrin family cellular adhesion molecules LFA-1, Mac-1 and IL-6 in acute necrotizing pancreatitis complicated with multiple organ injury.
METHODS The flow cytometer was used to detect the expression of LFA-1 and Mac-1 on leukocyte and the radio-immunity to detect the IL-6 in acute necrotizing pancreatitis of rats at different time points.
RESULTS The expression of LFA-1 and Mac-1 increased significantly in acute pancreatitis group compared with that in control group at all time points (P<0.01), i.e.: LFA-1: 1 h, 7.6±0.4 vs 22.7±1.6; 3 h, 7.9±0.5 vs 26.7±5.5; 6 h, 13.5±1.8 vs 30.3±1.6; 12 h, 9.7±0.7 vs 20.3±4.2; 24 h, 10.1±1.1 vs 15.9±0.7. Mac-1: 1 h, 6.2±1.1 vs 7.0±2.5; 3 h, 6.3±0.8 vs 36.0±1.5; 6 h, 7.9±1.2 vs 27.1±1.4; 12 h, 6.4±0.4 vs 22.5±2.1; 24 h, 7.1±0.4 vs 20.6±1.6. Expression of IL-6 increased significantly in acute pancreatitis group compared with that in control group, i.e.: 1 h, 65.6±3.2 vs 72.4±4.0 (P<0.05); 3 h, 68.2±5.5 vs 155.3±16.3 (P<0.01); 6 h, 69.3±2.6 vs 229.2±16.4 (P<0.01); 12 h, 73.4±2.6 vs 287.7±13.9 (P<0.01); 24 h, 76.9±3.3 vs 289.5±16.1 (P<0.01). Morphological examination demonstrated that inflammatory cells, insterstitial edema, interstitial hemorrhage, desquamation and disintegration occurred in the lungs and kidneys.
CONCLUSION IL-6, LFA-1 and Mac-1 may play the very active role in acute pancreatitis.
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Affiliation(s)
- Wei Sun
- Department of General Surgery, 2nd Hospital of China Medical University, Shenyang 110003, Liaoning Province, China
| | - Jun-Dong Zhang
- Department of General Surgery, The First Hospital of Daqing City, Daqing 163001, Heilongjiang Province, China
| | - Ying Zhao
- Department of General Surgery, 2nd Hospital of China Medical University, Shenyang 110003, Liaoning Province, China
| | - Yu Zhao
- Department of General Surgery, 2nd Hospital of China Medical University, Shenyang 110003, Liaoning Province, China
| | - Qiang Wang
- Department of General Surgery, 2nd Hospital of China Medical University, Shenyang 110003, Liaoning Province, China
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Sun B, Li HL, Gao Y, Xu J, Jiang HC. Factors predisposing to severe acute pancreatitis: evaluation and prevention. World J Gastroenterol 2003; 9:1102-5. [PMID: 12717866 PMCID: PMC4611382 DOI: 10.3748/wjg.v9.i5.1102] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze factors predisposing to the infections associated with severe acute pancreatitis (SAP) and to work out ways for its prevention.
METHODS: Total 208 cases of SAP treated in this hospital from Jan. 1980 to Dec. 2001 were retrospectively analyzed.
RESULTS: Statistical difference in the incidence of the aforementioned infections was found between the following pairs: between the groups of bloody or non-bloody ascites, paralytic ileus lasting shorter or longer than 5 days, Ranson scores lower or higher than 5, hematocrit lower or higher than 45%, CT Balthazar scores lower or higher than 7 and between 1980.1-1992.6 or 1992.7-2001.12 admissions (χ2 > 3.84, P < 0.05), while no statistical difference was established between the groups of biliogenic and non-biliogenic pancreatitis, serum amylase < 200 U/L and ≥ 200 U/L, serum calcium < 2 mmol/L and ≥ 2 mmol/L or groups of total parenteral nutrition shorter or longer than 7 days (χ2 < 3.84, P > 0.05).
CONCLUSION: Occurrence of infection in patients with SAP is closely related with bloody ascites, paralytic ileus ≥ 5 days, Ranson scores ≥ 5, hematocrit ≥ 45% and CT Balthazar Scores ≥ 7, but not with pathogens, serum calcium and total parenteral nutrition (TPN). Comprehensive prevention of pancreatic infection and practice of individualized therapy contribute to reducing the incidence of infection.
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Affiliation(s)
- Bei Sun
- Department of General Surgery, First Clinical Hospital, Harbin Medical University, China.
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