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New Trends in the Treatment of Severe Acute Pancreatitis

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The High-risk Surgical Patient

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Abstract

About one out of five patients with acute pancreatitis develop necrotizing pancreatitis associated with organ dysfunctions and considerable mortality. Organ dysfunction-based severity classification and contrast-enhanced computed tomography (CT) few days after admission are used to determine and categorize the severity of the disease. Moderate fluid resuscitation monitoring the response, regular measurements of intra-abdominal pressure, and early enteral feeding are the cornerstones of the early phase of management. At our institution, a short course of prophylactic antibiotics is administered in patients requiring treatment in the intensive care unit.

In addition to organ failures, the major determinant of the outcome is the development of infected necrosis. The diagnosis is based on clinical deterioration and imaging, and CT-guided fine needle aspiration is no longer used in most institutions. The diagnosis can be confirmed and management started following a step-up strategy, which is initiated with percutaneous insertion of one or more catheters to the necrotic areas. If catheter drainage is ineffective, it is followed by some form of necrosectomy preferably postponed until 4 weeks from the onset of the disease.

Other complications, such as bleeding, abdominal compartment syndrome, colonic perforation, and gangrenous cholecystitis, can develop at any time and require prompt intervention. In severe biliary pancreatitis, cholecystectomy should be delayed until the inflammatory response resolves and clinical recovery occurs, but early endoscopic retrograde cholangiopancreatography is indicated in patients with cholangitis and/or common bile duct obstruction.

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References

  1. Roberts SE, Morrison-Rees S, John A, et al. The incidence and aetiology of acute pancreatitis in Europe. Pancreatology. 2017;17:155–65.

    PubMed  Google Scholar 

  2. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102–11.

    PubMed  Google Scholar 

  3. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013;13(4 Suppl 2):e1–15. https://doi.org/10.1016/j.pan.2013.07.063.

    Article  Google Scholar 

  4. Dellinger EP, Forsmark CE, Layer P, et al. Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg. 2012;256:875–80.

    PubMed  Google Scholar 

  5. Cho JH, Kim TN, Chung HH, et al. Comparison of scoring systems in predicting the severity of acute pancreatitis. World J Gastroenterol. 2015;21:2387–94.

    PubMed  PubMed Central  Google Scholar 

  6. Leppäniemi A, Tolonen M, Tarasconi A, et al. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg. 2019;14:27. https://doi.org/10.1186/s13017-019-0247-0.

    Article  PubMed  PubMed Central  Google Scholar 

  7. de Madaria E, Soler-Sala G, Sanchez-Paya UJ, et al. Influence of fluid therapy on the prognosis of acute pancreatitis: a prospective cohort study. Am J Gastroenterol. 2011;106:1843–50.

    PubMed  Google Scholar 

  8. Rada G, Pena J. Is antibiotic prophylaxis beneficial in acute pancreatitis? – first update. Medwave. 2015;15:e6125.

    PubMed  Google Scholar 

  9. Ukai T, Shikata S, Inoue M, et al. Early prophylactic antibiotics administration for acute necrotizing pancreatitis: a meta-analysis of randomized controlled trials. J Hepatobiliary Pancreat Sci. 2015;22:316–21.

    PubMed  Google Scholar 

  10. Al Omran M, Albalawi ZH, Tashkandi ME, et al. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Rev. 2010;1:CD002837.

    Google Scholar 

  11. van Baal MC, Besselink MG, Bakker OJ, et al. Timing of cholecystectomy after mild biliary pancreatitis. Ann Surg. 2012;255:860–6.

    PubMed  Google Scholar 

  12. Gurusamy KS, Nagendran M, Davidson BR. Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database Syst Rev. 2013:CD010326.

    Google Scholar 

  13. Falor AE, de Virgilio C, Stabile BE, et al. Early laparoscopic cholecystectomy for mild gallstone pancreatitis. Time for a paradigm shift. Arch Surg. 2012;147:1031–5.

    PubMed  Google Scholar 

  14. Dubina ED, de Virgilio C, Simms ER, Kim DY, Moazzez A. Association of early vs delayed cholecystectomy for mild gallstone pancreatitis with perioperative outcomes. JAMA Surg. 2018;153:1057–9.

    PubMed  PubMed Central  Google Scholar 

  15. Mueck KM, Wei S, Pedroza C, et al. Gallstone pancreatitis. Admission versus normal cholecystectomy—a randomized trial (gallstone PANC trial). Ann Surg. 2019;270:519–27.

    PubMed  Google Scholar 

  16. Nealon WH, Bawduniak J, Walser EM. Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections. Ann Surg. 2004;239:741–51.

    PubMed  PubMed Central  Google Scholar 

  17. Petrov MS, Shanbhag S, Chakraborty M, et al. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology. 2010;139:813–20.

    PubMed  Google Scholar 

  18. Werge M, Novovic S, Schmidt PN, et al. Infection increases mortality in necrotizing pancreatitis: a systematic review and meta-analysis. Pancreatology. 2016;16:698–707.

    PubMed  Google Scholar 

  19. De Waele JJ. Rational use of antimicrobials in patients with severe acute pancreatitis. Semin Respir Crit Care Med. 2011;32:174–80.

    PubMed  Google Scholar 

  20. Guarner-Argente C, Buchner A, Ahmad NA, et al. Use of antimicrobials for EUS-guided FNA of pancreatic cysts: a retrospective, comparative analysis. Gastrointest Endosc. 2011;74:81–6.

    PubMed  Google Scholar 

  21. Chen HZ, Ji L, Li L, et al. Early prediction of infected pancreatic necrosis secondary to necrotizing pancreatitis. Medicine (Baltimore). 2017;96:e7487.

    PubMed  Google Scholar 

  22. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010;362:1491–502.

    PubMed  Google Scholar 

  23. Hollemans RA, Bollen TL, van Brunschot S, et al. Predicting success of catheter drainage in infected necrotizing pancreatitis. Ann Surg. 2016;263:787–92.

    PubMed  Google Scholar 

  24. van Brunschot S, van Grinsven J, van Santvoort HC, et al. Endoscopic or surgical step-up approach for infected necrotizing pancreatitis. A multicentre randomized trial. Lancet. 2018;391:51–8.

    PubMed  Google Scholar 

  25. van Brunschot S, Hollemans RA, Bakker OJ, et al. Minimally invasive and endoscopic versus open necrosectomy for necrotizing pancreatitis: a pooled analysis of individual data for 1980 patients. Gut. 2018;67:697–706.

    PubMed  Google Scholar 

  26. Wang YB, Yang XL, Chen L, et al. Retroperitoneal versus open intraperitoneal necrosectomy in step-up therapy for infected necrotizing pancreatitis: a meta-analysis. Int J Surg. 2018;56:83–93.

    PubMed  Google Scholar 

  27. Husu HL, Kuronen JA, Leppäniemi AK, Mentula PJ. Open necrosectomy in acute pancreatitis – obsolete or still useful? World J Emerg Surg. 2020;15:21. https://doi.org/10.1186/s13017-020-00300-9.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Driedger M, Zyromski NJ, Visser B, et al. Surgical transgastric necrosectomy for necrotizing pancreatitis - a single-stage procedure for walled-off pancreatic necrosis. Ann Surg. 2020;271:163–8.

    PubMed  Google Scholar 

  29. Evans RPT, Mourad MM, Pall G, et al. Pancreatitis: preventing catastrophic haemorrhage. World J Gastroenterol. 2017;23:5460–8.

    PubMed  PubMed Central  Google Scholar 

  30. Ai M, Lu GM, Xu J. Endovascular embolization of arterial bleeding in patients with severe acute pancreatitis. Videosurgery Miniinv. 2019;14:401–7.

    Google Scholar 

  31. Flati G, Andren-Sandberg Å, La Pinta M, et al. Potentially fatal bleeding in acute pancreatitis: pathophysiology, prevention, and treatment. Pancreas. 2003;26:8–14.

    PubMed  Google Scholar 

  32. Bergert H, Hinterseher I, Kersting S, et al. Management and outcome of hemorrhage due to arterial pseudoaneurysms in pancreatitis. Surgery. 2005;137:323–8.

    PubMed  Google Scholar 

  33. Li H, Yang Z, Tian F. Clinical characteristics and risk factors for sinistral portal hypertension associated with moderate and severe acute pancreatitis: a seven-year single-center retrospective study. Med Sci Monit. 2019;25:5969–76.

    PubMed  PubMed Central  Google Scholar 

  34. Murage KP, Ball CB, Zyromski NJ, et al. Clinical framework to guide operative decision making in disconnected left pancreatic remnant (DLPR) following acute or chronic pancreatitis. Surgery. 2010;148:847–56.

    PubMed  Google Scholar 

  35. van Brunschot S, Schut AJ, Bouwense SA, et al. Abdominal compartment syndrome in acute pancreatitis. A systematic review. Pancreas. 2014;43:665–74.

    PubMed  Google Scholar 

  36. Cheatham ML, Safcsak K. Percutaneous catheter decompression in the treatment of elevated intraabdominal pressure. Chest. 2011;140:1428–35.

    CAS  PubMed  Google Scholar 

  37. Pupelis G, Plaudis H, Zeiza K, et al. Early continuous veno-venous haemofiltration in the management of severe acute pancreatitis complicated with intra-abdominal hypertension: retrospective review of 10 years' experience. Ann Intensive Care. 2012;2(Suppl 1):S21. https://doi.org/10.1186/2110-5820-2-S1-S21.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Mentula P, Hienonen P, Kemppainen E, et al. Surgical decompression for abdominal compartment syndrome in severe acute pancreatitis. Arch Surg. 2010;145:764–9.

    PubMed  Google Scholar 

  39. Petersson U, Acosta S, Björck M. Vacuum-assisted wound closure and mesh-mediated fascial traction—a novel technique for late closure of the open abdomen. World J Surg 2007; 31: 2133–2137.

    Google Scholar 

  40. Rasilainen SK, Mentula PJ, Leppäniemi AK. Vacuum and mesh-mediated fascial traction for primary closure of the open abdomen in critically ill surgical patients. Br J Surg. 2012;99:1725–32.

    CAS  PubMed  Google Scholar 

  41. Atema JJ, Gans SL, Boermeester MA. Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. World J Surg. 2015;39:912–25.

    CAS  PubMed  Google Scholar 

  42. Mohamed SR, Siriwardena AK. Understanding the colonic complications of pancreatitis. Pancreatology. 2008;8:153–8.

    PubMed  Google Scholar 

  43. Nakanishi N, Shimono T, Yamamoto A, et al. CT evaluation and clinical factors predicting delayed colonic perforation following acute pancreatitis. Jpn J Radiol. 2016;34:10–5.

    PubMed  Google Scholar 

  44. Chen EZ, Huang J, Xu ZW, et al. Clinical features and outcomes of patients with severe acute pancreatitis complicated with gangrenous cholecystitis. Hepatobiliary Pancreat Dis Int. 2013;12:317–23.

    PubMed  Google Scholar 

  45. Schepers NJ, Bakker OJ, Besselink M, et al. Impact of characteristics of organ failure and infected necrosis on mortality in necrotizing pancreatitis. Gut. 2019;68(6):1044–51. https://doi.org/10.1136/gutjnl-2017-314657. Epub 2018 Jun 27.

    Article  CAS  PubMed  Google Scholar 

  46. Halonen KI, Pettilä V, Leppäniemi AK, et al. Multiple organ dysfunction associated with severe acute pancreatitis. Crit Care Med. 2002;30:1274–9.

    PubMed  Google Scholar 

  47. Husu HL, Leppäniemi AK, Lehtonen TM, et al. Short- and long-term survival after severe acute pancreatitis: a retrospective 17 years’ cohort study from a single center. J Crit Care. 2019;53:81–6.

    PubMed  Google Scholar 

  48. Karjula H, Saarela A, Ohtonen P, et al. Long-term outcome and causes of death for working-age patients hospitalized due to acute pancreatitis with a median follow-up of 10 years. Ann Surg. 2019;269:932–6.

    PubMed  Google Scholar 

  49. Halonen K, Pettilä V, Leppäniemi A, et al. Long-term health-related quality of life in survivors of severe acute pancreatitis. Intensive Care Med. 2003;29:782–6.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Emergency Surgery, Abdominal Center, Helsinki University Hospital Meilahti, Helsinki, Finland

    Ari Leppäniemi & Matti Tolonen

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  1. Ari Leppäniemi
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  2. Matti Tolonen
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Correspondence to Ari Leppäniemi .

Editor information

Editors and Affiliations

  1. Dipartimento di Emergenza Urgenza, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Paolo Aseni

  2. Divisione di Cardiochirurgia, IRCCS Fondazione Policlinico San Matteo, Pavia, Pavia, Italy

    Antonino Massimiliano Grande

  3. Div. of Emerg. Surg., Abdominal Center, Helsinki University Hospital Meilahti, Helsinki, Finland

    Ari Leppäniemi

  4. Department of Pathophysiology and Transplantation, General Surgery and Trauma Team, University of Milano, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Osvaldo Chiara

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Leppäniemi, A., Tolonen, M. (2023). New Trends in the Treatment of Severe Acute Pancreatitis. In: Aseni, P., Grande, A.M., Leppäniemi, A., Chiara, O. (eds) The High-risk Surgical Patient. Springer, Cham. https://doi.org/10.1007/978-3-031-17273-1_24

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  • DOI: https://doi.org/10.1007/978-3-031-17273-1_24

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  • Publisher Name: Springer, Cham

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  • Online ISBN: 978-3-031-17273-1

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