INCIDENCE OF ACUTE PANCREATITIS 5 – 80 / 100.000 Jiang K, Chen XZ, Xia Q, Tang WF, Wang L. Early...

INCIDENCE OF ACUTE PANCREATITIS

5 – 80 / 100.000

Jiang K, Chen XZ, Xia Q, Tang WF, Wang L. Early nasogastric enteral nutrition for severe acute pancreatitis: A systematic review. World J Gastroenterol 2007;13(39):5253-5260

41

31,7

27,3Biliary

Alcohol

Other

ETIOLOGY

Lankisch, Dig Dis Sci 2001.

Meta analysis 20 studies, >100 patients/study

NATURAL HISTORY

Lankisch et al, Am J Gastroenterol 2009; 104:2797–2805;.

Study flowchart: natural history of 532 patients diagnosed with a first attack of acute pancreatitis

RELAPSE RATE

Lankisch et al, Am J Gastroenterol 2009; 104:2797–2805;.

Relapse rate after the first attack of acute pancreatitis according to its etiology

Olah A, Romics Jr. L. Early enteral nutrition in acute pancreatitis – benefits and limitations. Langenbecks Arch Surg 2008;

Infected necrosis (30-40%)

↓

Mortality ~ 30%

Mortality < 1%

SEVERITY OF ACUTE PANCREATITIS

RANSON CRITERIA BANK'S CRITERIA BALTHAZARVariations:Imrie (Glasgow), many single or more + peritoneal fluid Variations:

MOF/MOD, SOF/LOD, Bernards OF score, Apache II, Atlanta

% Necrosis

Newer:procalcitonin, serum amyloid A, complement (3a + SC5-9), gene for IL-10 locus

Other:CRP, SIRS, IL-6, IL-8, pyridinium split products, urine TAP, hemoconcentrationMOF indicates multiple organ failure; SOF, Sequential Organ Failure; CRP, C-reactive protein; SIRS, systemic inflammatory response syndrome.

Al-Bahrani AZ et al. Pancreas 2008; 36:39-43

Admission APP vs. APACHE II score in the prediction of mortality in patients with SAP.

THE PROGNOSTIC ROLE OFABDOMINAL PERFUSION PRESSURE IN SAP

Frossard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet 2008;371:143-52.

Bang UC, Semb S, Nojgaard C, Bendtsen F. Pharmacological approach to acute pancreatitis. World J Gastroenterol 2008;14(19):2968-2976.

Overview of drugs tested in animal experimental models and clinical trials

PHARMACOLOGICAL TREATMENT IN PHARMACOLOGICAL TREATMENT IN ACUTE PANCREATITISACUTE PANCREATITIS

Neoptolemos, Lancet 1988;2:979-983Neoptolemos, Lancet 1988;2:979-983Folsch, N Engl J Med 1997;336:237-242Folsch, N Engl J Med 1997;336:237-242Kozark, Gastrointest Endosc 2002;56(Suppl):231-236Kozark, Gastrointest Endosc 2002;56(Suppl):231-236

High mortality rate in patients with biliary sepsis with impacted stones

Biliary obstruction, dilated bile duct, cholangitis – urgent ERCP/ES and stone extraction

ERCPERCP – therapeutic indications – therapeutic indications

Van Santvoort et al. Ann Surg 2009; 250(1):68-75.

EARLY ERCP vs. CONSERVATIVE THERAPY

Van Santvoort et al. Ann Surg 2009; 250(1):68-75.

IS NUTRITION SO IMPORTANT?

MILD AP • Little influence on nutritional status and metabolism

SEVERE AP

• Increased energy expenditure• Hypermetabolism

• Protein catabolism (negative nitrogen balance up to 40 g/day)

• Malnutrition

Meier R, Ockenga J, Pertkiewicz M, Pap A, Milinic N, MacFie J. ESPEN guidelines on enteral nutrition: Pancreas. Clin Nutr 2006;25:275-284.

MILD AP• No need for enteral nutrition• Normal food after 5 – 7 days• If oral food not tolerated – intrajejunal supply after 5 days

ESPEN GUIDELINES 2006.

SEVERE AP• Early enteral nutrition if feasible• Parenteral nutrition supplement if needed• Oral food intake as soon as possible


ENTERAL NUTRITION vs. TOTAL PARENTERAL NUTRITION


ENTERAL NUTRITION vs. PARENTERAL NUTRITION

Marik PE. Current Opinion in Critical Care 2009; 15:131-138

Effect of route of nutritional support on the acquisition of new infections

LOWER INCIDENCE• Infection• Surgical intervention• Lenght of hospital stays

No significant difference in mortality rates and noninfective complications


ENTERAL NUTRITION vs. TOTAL PARENTERAL NUTRITION

Greenwood JK, Lovelace HY, MyClave SA. Enteral nutrition in acute pancreatitis: a survey of practices in Canadian intensive care units. Nutr Clin Pract 2004;19:31-6.

Pezzilli R, Uomo G, Gabbrielli A, et al. ProInf-AISP Study Group: a prospective multicentre survey on the treatment of acute pancreatitis in Italy. Dig Liver Dis 2007;39:838-46.

FREQUENCY OF “EN” ADMINISTRATION

Intrajejunal administration

Standard formula

Peptid-based formula

If not tolerated


Petrov MS et al. British Journal of Surgery 2009; 96:1243-52

Comparison of different enteral nutrition formulations

Pooled estimates and sensitivity analysis

Funnel plot of included trials

Neither the supplementation of enteral nutrition with probiotics nor the use of immunonutrition significantly improves the clinical outcomes.

STUDY CONCLUSIONS

The use of polymeric vs. (semi)elemental formulation leads to no significantly higher risk of feeding intolerance, infectious complications or death.

Petrov MS, Loveday BPT, Pylypchuk RD, McIlroy K, Phillips ARJ, Windsor JA. British Journal of Surgery 2009; 96:1243-52

Besselink MGH et al. Lancet 2008; 371:651-59

PROBIOTIC PROPHYLAXIS IN PREDICTED SEVERE ACUTE PANCREATITIS

Pooled Kaplan-Meier time-to-event analysis for mortality in the first 90 days after randomization.

Drugs that penetrate pancreatic tissue and decontaminate the gut to prevent translocation (imipenem, ciprofloxacin, metronidazole)

Reduced infection rates in SAP, but not improved survival

(Uhl,Pancreatology, 2002;2:565-573)

Candida species infections in SAP treated with prophylactic antibiotics 20-40%

(Gloor, Pancreatology 2001;1:213-216)

Yu Bai, M.D., Jun Gao, Duo-Wu Zou, Zhao-Shen Am J Gastroenterol 2008;103:104–110

Prophylactic Antibiotics Cannot Reduce Infected Pancreatic Necrosis and Mortality in Acute

Necrotizing Pancreatitis: Evidence From a Meta-Analysis of Randomized

Controlled Trials

95/467 patients developed infected pancreatic necrosis (42;17.8% treatment group vs. 53;22.9% controls)

Not statistically significant (RR 0.81, 95% CI 0.54-1.22, P=0.32)

RESULTS

57/467 patients died (22;9.3% treatment group vs. 35;15.2% controls)

Not statistically significant (RR 0.70, 95% CI 0.42-1.17, P=0.17)

RESULTS

Is prophlylactic use of antibiotics protective in severe acute pancreatitis?

Jafri NS et al. The American Journal of Surgery 2009; 197:806-813

Pooled Meta-analysis of prophylactic antibiotics versus placebo/no intervention effect on mortality.

• Antibiotic prophylaxis meta-analyses limitations:– Primary study design limitations (inclusion criteria, antibiotic

duration and dosing, nutritional support, resuscitative measures)– Relatively small number of patients– Different outcome measurements– Inclusion of nonblinded studies

• Additional, well-carried out studies are needed! (especially regarding adverse effects, duration of therapy and impact of etiology on infection outcome)

Most devastatingcomplication of AP

Occur in 1-10% of AP patients

Account for almost 80% of all deaths

Areas of necrosis with positive smear, gram stain orculture for bacteria or funghi (FNA-US or CT guided)

In surgically treated mortality 10-59%

In medically treated (without drainage) 100%

Navaneethan U, Vege SS, Chari ST, Bron TH; Pancreas 2009; 38:867-875

MINIMALLY INVASIVE TECHNIQUES IN PANCREATIC NECROSIS


PERCUTANEOUS DRAINAGE FOR PANCREATIC NECROSIS


ENDOSCOPIC THERAPY FOR PANCREATIC NECROSIS


LAPAROSCOPIC TECHNIQUE FOR PANCREATIC NECROSIS


RETROPERITONEAL APROACH FOR PANCREATIC NECROSIS

SURGICAL NECROSECTOMY

• Open necrosectomy with open packing and planned re-laparotomy

• Open necrosectomy with planned re-laparotomy, staged and repeated lavage

• Open necrosectomy eith continous lavage of lesser sac and retroperitoneum

• Open necrosectomy with closed packing

Tonsi et al. World J Surg 2009

Early surgery (within 48 h) in gallstone pancreatitis –

higher mortality

Discharged patients with gallstone pancreatitis – reccurence up to 63%

(Uhl, Pancreatology 2002;2:565-573(Uhl, Pancreatology 2002;2:565-573

Need for surgery - IPN proven by FNA (when septic complications develop)

Early <14 days after onset > late surgery ?

Yang Dj et al. Chin Med J 2009; 122(13):1492-94

THE ROLE OF EARLY SURGERY IN FAP(FULMINANT ACUTE PANCREATITIS)

• FAP - the presence of organ dysfunction within 72h after onset of symptoms despite intensive care treatment

Comparison of mortality between the study groups(conservative therapy, early and late surgery group)

Epidemiology of IAH and ACS in patients with SAP

De Waele JJ, Leppäniemi AK Intra-Abdominal Hyprtension in Acute Pancreatitis. World J Surg 2009; 33:1128-1133

Chen H, Li F, Sun JB, Jia JG. World J gastroenterol 2008; 14(22):3541-8

ABDOMINAL COMPARTMENT SYNDROME (ACS)

Comparison of complications and outcome between patients with and without ACS

PREVENTION OF IAHin patients with severe AP


AlbuminJudicious use

of NaCl

aim: reduce overhydration

Colloids

NONSURGICAL TREATMENT OF IAH in patients with severe AP


Percutaneous ascites drainage

NG tube

aim: reduce IAP

Neuromuscular blockers (short-term use)

Hemodialysis

SURGICAL DECOMPRESSION OF IAHin patients with severe AP

De Waele JJ, Leppäniemi AK. World J Surg 2009; 33:1128-1133

Does it work• IAP significantly lowered

Does it help• controversial data• mortality is higher in patients with:

•preoperative renal failure•lower preoperative IAP•late decompression (after 7 days)

SURGICAL DECOMPRESSION OF IAHin patients with severe AP

Is it safe ???• retroperitoneal hemorrhage• prolonged course• multiple reoperations• high risk of complications

De Waele JJ, Leppäniemi AK. World J Surg 2009; 33:1128-1133

• subcutaneous fasciotomy – safest

Bang UC, Semb S, Nojgaard C, Bendtsen F. Pharmacological approach to acute pancreatitis. World J Gastroenterol 2008;14(19):2968-2976.

EARLY RECOGNITION EARLY RECOGNITION -SEVERITY SIGNS -SEVERITY SIGNS

EARLY ICU EARLY ICU RATIONALE RATIONALE THERAPYTHERAPY

Pharmacological prevention still impossiblePharmacological prevention still impossible

When would You like to start with enteral nutrition in patient with

SAP?

• A - on the day of admission

• B – on the 2nd day

• C – on the 3rd day

• D – after 3rd day

Which method do You prefer in detection of choledocholithiasis in

AP?

• A – ultrasound

• B – EUS

• C – MRCP

• D - ERCP

INCIDENCE OF ACUTE PANCREATITIS 5 – 80 / 100.000 Jiang K, Chen XZ, Xia Q, Tang WF, Wang L. Early...

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