INCIDENCE OF ACUTE PANCREATITIS · 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

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

27,3

Biliary

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;

80%

20%

Mild-moderate AP

Severe necrotizing AP

Infected necrosis

(30-40%)

↓

Mortality ~ 30%

Mortality < 1%

SEVERITY OF ACUTE PANCREATITIS

RANSON CRITERIA BANK'S CRITERIA BALTHAZAR

Variations:

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,

hemoconcentration

MOF 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 OF

ABDOMINAL 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

ACUTE PANCREATITIS


Neoptolemos, Lancet 1988;2:979-983

Folsch, N Engl J Med 1997;336:237-242

Kozark, 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

ERCP – 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.


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


Canada (ICU)

13

72

15

Routinely (%)Occasionally (%)Never (%)

Italy

4,7

95,3

EP+ (%)

EP- (%)

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 withprobiotics nor the use of immunonutrition significantlyimproves 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 devastating

complication of AP

Occur in 1-10% of AP patients

Account for almost 80% of all deaths

Areas of necrosis with positive smear, gram stain or

culture 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

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 IAH

in patients with severe AP


AlbuminJudicious use

of NaCl

aim: reduce overhydration

Colloids

NONSURGICAL TREATMENT OF IAH



Percutaneous

ascites drainage

NG tube

aim: reduce IAP

Neuromuscular blockers

(short-term use)

Hemodialysis

SURGICAL DECOMPRESSION OF IAH


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 IAH


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

-SEVERITY SIGNS

EARLY ICU RATIONALE

THERAPY

Pharmacological 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

Documents

INCIDENCE OF ACUTE PANCREATITIS · 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