Present and future of prophylactic antibiotics for severe acute pancreatitis

AIM: To investigate the role of prophylactic antibiotics in the reduction of mortality of severe acute pancreatitis (SAP) patients, which is highly questioned by more and more randomized controlled trials (RCTs) and metaanalyses. METHODS: An updated meta-analysis was performed. RCTs comparing prophylactic antibiotics for SAP with control or placebo were included for meta-analysis. The mortality outcomes were pooled for estimation, and re-pooled estimation was performed by the sensitivity analysis of an ideal large-scale RCT. RESULTS: Currently available 11 RCTs were included. Subgroup analysis showed that there was significant reduction of mortality rate in the period before 2000, while no significant reduction in the period from 2000 [Risk Ratio, (RR ) = 1.01, P = 0.98]. Funnel plot indi-cated that there might be apparent publication bias in the period before 2000. Sensitivity analysis showed that the RR of mortality rate ranged from 0.77 to 1.00 with a relatively narrow confidence interval (P < 0.05). However, the number needed to treat having a minor lower limit of the range (7-5096 patients) implied that certain SAP patients could still potentially prevent death by antibiotic prophylaxis. CONCLUSION: Current evidences do not support prophylactic antibiotics as a routine treatment for SAP, but the potentially benefited sub-population requires further investigations.

Effect of acupoint application combined with microwave treatment on the intestine barrier functional disturbance of moderately severe acute pancreatitis

Objective: To explore and analyze the effect of acupoint application combined with microwave treatment on the intestinal barrier dysfunction with moderately severe acute pancreatitis. Methods: A convenient sample of 90 moderately severe acute pancreatitis was selected from March 2017 to December 2017 in the comprehensive hospital with third grade in Tianjin. The patients were divided into group A (acupoint application combined with microwave treatment), group B (acupoint application) and group C (routine nursing). Thirty patients were included in each group. This study need to get the informed consent of the patients. Acupoint application combined with microwave treatment was used, basing on routine nursing measures in group A. Acupoint application was used by the same way and the same traditional Chinese medicine ,basing on routine nursing measures in group B. Routine nursing used in group C. C-reactive protein and the score of intestinal function were measured on 3 th day, 7 th day and 10 th day, after intervention. To record the effective ratio of the treatment after 10 days of intervention. Results: There are significant statistical difference among the three group after intervention (P < 0.05). Conclusion: In some way, acupoint application combined with microwave treatment are able to decrease the time about the recovery of intestinal barrier dysfunction in moderately severe acute pancreatitis and to alleviate the suffering of patients.

Comparison of early enteral nutrition in severe acute pancreatitis with prebiotic fiber supplementation versus standard enteral solution:A prospective randomized double-blind study

AIM: To compare the benefi cial effects of early enteral nutrition (EN) with prebiotic fiber supplementation in patients with severe acute pancreatitis (AP).METHODS: Thirty consecutive patients with severe AP, who required stoppage of oral feeding for 48 h, were randomly assigned to nasojejunal EN with or without prebiotics. APACHE Ⅱ score, Balthazar’s CT score and CRP were assessed daily during the study period.RESULTS: The median duration of hospital stay was shorter in the study group [10 ± 4 (8-14) d vs 15 ± 6 (7-26) d] (P < 0.05). The median value of days in intensive care unit was also similar in both groups [6 ± 2 (5-8) d vs 6 ± 2 (5-7) d]. The median duration of EN was 8 ± 4 (6-12) d vs 10 ± 4 (6-13) d in the study and control groups, respectively (P > 0.05). Deaths occurred in 6 patients (20%), 2 in the study group and 4 in the control group. The mean duration of APACHE Ⅱ normalization (APACHE Ⅱ score < 8) was shorter in the study group than in the control group (4 ± 2 d vs 6.5 ± 3 d, P < 0.05). The mean duration of CRP normalization was also shorter in the study group than in the control group (7 ± 2 d vs 10 ± 3 d, P < 0.05).CONCLUSION: Nasojejunal EN with prebiotic fiber supplementation in severe AP improves hospital stay, duration nutrition therapy, acute phase response and overall complications compared to standard EN therapy.

Continuous regional arterial infusion therapy with gabexate mesilate for severe acute pancreatitis

AIM： To evaluate the efficacy of continuous regional arterial infusion therapy （CRAI） with gabexate mesilate and antibiotics for severe acute pancreatitis （SAP）. METHODS： We conducted a prospective study on patients who developed SAP with or without CRAI. Out of 18 patients fulfilled clinical diagnostic criteria for SAP in Japan, 9 patients underwent CRAI, while 9 patients underwent conventional systemic protease inhibitor and antibiotics therapy （non-CRAI）. CRAI was initiated within 72 h of the onset of pancreatitis. Gabexate mesilate （2400 mg/d） was continuously administered for 3 to 5 d. The clinical outcome including serum inflammation-related parameters were examined. RESULTS- The duration of abdominal pain in the CRAI group was 1.9 =1：0.26 d, whereas that in the non-CRAI group was 4.3 ±0.50. The duration of SIRS in the CRAI group was 2.2 ± 0.22 d, whereas that in the non- CRAI group was 3.2 ± 0.28. Abdominal pain and SIRS disappeared significantly in a short period of time after the initiation of CRAI using gabexate mesilate. The average length of hospitalization significantly differed between the CRAI and non-CRAI groups, 53.3 ± 7.9 d and 87.4± 13.9 d, respectively. During the first two weeks, levels of serum CRP and the IL6/IL10 ratio in the CRAI group tended to have a rapid decrease compared to those in the non-CRAI group. CONCLUSION： The present results suggest that CRAI using gabexate mesilate was effective against SAP.

Diagnosis and Management of Severe Acute Pancreatitis Complicated with Abdominal Compartment Syndrome

Presented in this paper is our experience in the diagnosis and management of abdominal compartment syndrome during severe acute pancreatitis. On the basis of the history of severe acute pancreatitis, after effective fluid resuscitation, if patients developed renal, pulmonary and cardiac insufficiency after abdominal expansion and abdominal wall tension, ACS should be considered. Cystometry could be performed to confirm the diagnosis. Emergency decompressive celiotomy and temporary abdominal closure with a 3 liter sterile plastic bag must be performed. It is also critical to prevent reperfusion syndrome. In 23 cases of ACS, 18 cases received emergency decompressive celiotomy and 5 cases did not. In the former, 3 patients died (16.7 %) while in the later, 4 (80%) died. Total mortality rate was 33.3% (7/21). In 7 death cases, 4 patients developed acute obstructive suppurative cholangitis (AOSC). All the patients who received emergency decompressive celiotomy 5 h after confirmation of ACS survived. The definitive abdominal closure took place mostly 3 to 5 days after emergency decompressive celiotomy, with longest time being 8 days. 6 cases of ACS at infection stage were all attributed to infected necrosis in abdominal cavity and retroperitoneum. ACS could occur in SIRS stage and infection stage during SAP, and has different pathophysiological basis. Early diagnosis, emergency decompressive celiotomy and temporary abdominal closure with a 3L sterile plastic bag are the keys to the management of the condition.

Study progress in therapeutic effects of traditional Chinese medicine monomer in severe acute pancreatitis

Severe acute pancreatitis (SAP) is a common acute abdomen clinical problem characterized by high mortality, mul-tiple complications, complicated pathogenesis and difficult treatment. Recent studies found traditional Chinese medicine (TCM) monomers have markedly good effect for treating SAP. Many TCM monomers can inhibit pancreatin, resist inflammation, im-prove microcirculation and immunoloregulation, etc. to block the pathological progress of SAP in multiple ways, reduce com-plications and lower mortality with rapid effects. It is significant for enhancing SAP treatment to deeply understand the current situation in TCM monomers for treating SAP and take precious references therein. This article summarizes the treating effects and mechanisms of TCM monomers for SAP in recent years.

Antibiotic prophylaxis in patients with severe acute pancreatitis

BACKGROUND: The prophylactic use of antibiotics in pa- tients with severe acute pancreatitis remains contentious. This study was undertaken to review the current studies on antibiotic prophylaxis in patients with severe acute pancrea- titis. DATA RESOURCES: All papers found by a Medline search were relevant to human trials of antibiotic prophylaxis in patients with severe acute pancreatitis. RESULTS: In the 1970s, three small randomized studies of prophylactic ampicillin in the treatment of acute pancreati- tis showed no effect on mortality or morbidity, but the in- clusion of patients at low risk for infection and the use of an ineffective antibiotic were insufficient to detect any diffe- rences. From 1993 to 2001, eight prospective clinical trials of antibiotic prophylaxis were conducted in patients with severe acute pancreatitis ( SAP ). Seven of the 8 trials showed significant effect of the prophylaxis in prevention of pancreatic infections, and one showed significant improve- ment of clinical course documented by the Acute Physiolo- gy and Chronic Health Evaluation (APACHE ) scores. Only two trials did demonstrate the significance of the prophylaxis in lowering the mortality rate. Despite varia- tions in drug agents, study size and patient selection, dura- tion of treatment, and methodology ( None of the studies was double-blinded), a meta-analysis showed the positive effect of antibiotics in reducing the mortality. We suggested that antibiotic prophylaxis with proven efficacy in necrotic pancreatic tissues should be given to all patients with acute necrotizing pancreatitis. In recent years, however, the first double-blind, placebo-controlled multicenter study from Germany detected no benefit of antibiotic prophylaxis with respect to the risk of developing infected pancreatic necrosis. CONCLUSION: Prophylactic antibiotics for severe acute pancreatitis is still a matter of discussion and further studies are required to provide adequate data to answer many ques-tions and to define the role of antibiotic prophylaxis in pa- tients with severe acute pancreatitis.

How severe is moderately severe acute pancreatitis? Clinical validation of revised 2012 Atlanta Classification

AIM To explore the outcomes and the appropriate treatment for patients with moderately severe acute pancreatitis(AP).METHODS Statistical analysis was performed on data from the prospectively collected database of 103 AP patients admitted to the Department of Surgery,Hospital of Lithuanian University of Health Sciences in 2008-2013. All patients were confirmed to have the diagnosis of AP during the first 24 h following admission. The severity of pancreatitis was assessed by MODS and APACHE Ⅱ scale. Clinical course was re-evaluated after 24,48 and 72 h. All patients were categorized into 3 groups based on Atlanta 2012 classification: Mild,moderately severe,and severe.Outcomes and management in moderately severe group were also compared to mild and severe cases according to Atlanta 1992 and 2012 classification.RESULTS Fifty-three-point four percent of patients had edematous while 46.6 % were diagnosed with necrotic AP. The most common cause of AP was alcohol(42.7%) followed by alimentary(26.2%),biliary(26.2%) and idiopathic(4.9%). Under Atlanta 1992 classification 56(54.4%) cases were classified as "mild" and 47(45.6%) as "severe". Using the revised classification(Atlanta 2012),the patient stratification was different: 49(47.6%) mild,27(26.2%) moderately severe and 27(26.2%) severe AP cases. The two severe groups(Atlanta 1992 and Revised Atlanta 2012) did not show statistically significant differences in clinical parameters,including ICU stay,need for interventional treatment,infected pancreatic necrosis or mortality rates. The moderately severe group of 27 patients(according to Atlanta 2012) had significantly better outcomes when compared to those 47 patients classified as severe form of AP(according to Atlanta 1992) with lower incidence of necrosis and sepsis,lower APACHE Ⅱ(P = 0.002) and MODS(P = 0.001) scores,shorter ICU stay,decreased need for interventional and surgical treatment.CONCLUSION Study shows that Atlanta 2012 criteria are more accurate,reduce unnecessary treatments for patients with mild and moderate severe pancreatitis,potentially resulting in health costs savings.

Analysis of the risk factors for severity in post endoscopic retrograde cholangiopancreatography pancreatitis: The indication of prophylactic treatments

To determine the risk factors of severe post endoscopic retrograde cholangiopancreatography pancreatitis (sPEP) and clarify the indication of prophylactic treatments. METHODSAt our hospital, endoscopic retrograde cholangiopancreatography (ERCP) was performed on 1507 patients from May 2012 to December 2015. Of these patients, we enrolled all 121 patients that were diagnosed with post endoscopic retrograde PEP. Fourteen of 121 patients diagnosed as sPEP were analyzed. RESULTSForty-one patients had contrast media remaining in the pancreatic duct after completion of ERCP. Seventy-one patients had abdominal pain within three hours after ERCP. These were significant differences for sPEP (P < 0.05). The median of Body mass index, the median time for ERCP, the median serum amylase level of the next day, past histories including drinking and smoking, past history of pancreatitis, sphincter of Oddi dysfunction, whether emergency or not, expertise of ERCP procedure, diverticulum nearby Vater papilla, whether there was sphincterotomy or papillary balloon dilation, pancreatic duct cannulation, use of intra-ductal ultrasonography enforcement, and transpapillary biopsies had no significant differences with sPEP. CONCLUSIONContrast media remaining in the pancreatic duct and the appearance of abdominal pain within three hours after ERCP were risk factors of sPEP.

Treatment of severe acute pancreatitis through retroperitoneal laparoscopic drainage

A treatment method based on drainage via retroperitoneal laparoscopy was adopted for 15 severe acute pancreatitis(SAP)patients to investigate the feasibility of the method.Ten patients received only drainage via retroperitoneal laparoscopy,four patients received drainage via both retroperitoneal and preperitoneal laparoscopy,and one patient received drainage via conversion to laparotomy.Thirteen patients exhibited a good drainage effect and were successfully cured without any other surgical treatment.Two patients had encapsulated effusions or pancreatic pseudocysts after surgery,but were successfully cured after lavage and B ultrasound-guided percutaneous catheter drainage.SAP treatment via retroperitoneal laparoscopic drainage is an effective surgical method,resulting in minor injury.

Review:Advances in researches on the immune dysregulation and therapy of severe acute pancreatitis

During the development and progression of severe acute pancreatitis(SAP) ,conspicuous immune dysregulation develops,which is mainly manifested as excessive immune response in the early stage and immunosuppression in the late stage. This process involves complex changes in a variety of immune molecules and cells,such as cytokines,complements,lymphocytes,and leukocytes. With the gradual deepening of studies on the development and progression of SAP,the role of immune dysregulation in the pathogenesis of SAP has attracted more and more attention. In this article,we review the advances in research on the immune dysregulation in SAP and the immunotherapy of this disease through exploring the formation of excessive immune response and immune suppression as well as their mutual transformation.

Early phase of acute pancreatitis: Assessment and management

Acute pancreatitis(AP) is a potentially life-threatening disease with a wide spectrum of severity. The overall mortality of AP is approximately 5%. According to the revised Atlanta classification system, AP can be classified as mild, moderate, or severe. Severe AP often takes a clinical course with two phases, an early and a late phase, which should both be considered separately. In this review article, we first discuss general aspects of AP, including incidence, pathophysiology, etiology, and grading of severity, then focus on the assessment of patients with suspected AP, including diagnosis and risk stratification, followed by the management of AP during the early phase, with special emphasis on fluid therapy, pain management, nutrition, and antibiotic prophylaxis.

重症急性胰腺炎患者急救护理流程再造及应用效果

目的:探讨重症急性胰腺炎(severe acute pancreatitis,SAP)患者急救护理流程再造及应用效果。方法:选取2019年1月—2022年1月样本医院收治的94例SAP患者作为研究对象,将2019年1月—2020年6月样本医院收治的47例SAP患者设为对照组,将2020年7月—2021年12月应用基于流程再造理论重组院内SAP急救护理流程的47例SAP患者设为研究组,比较两组患者急救效率和救治结局。结果:研究组分诊时间、候诊时间和就诊时间均短于对照组,差异有统计学意义(t=12.743、9.136、7.075,P<0.05)。研究组再入院率低于对照组,差异有统计学意义(χ^(2)=4.424,P<0.05)。死亡率比较差异无统计学意义(χ^(2)=0.261,P>0.05)。研究组满意度评分高于对照组,差异有统计学意义(t=6.231,P<0.001)。结论:对SAP患者应用基于流程再造理论重组急救护理流程,可提高SAP急救效果,改善患者救治结局。

重症急性胰腺炎的治疗进展研究

重症急性胰腺炎(SAP)具有病情危重,病程进展快,并发症多,死亡率高的特点。SAP的早期诊断及早期干预治疗,对于降低患者并发症发生率和死亡风险具有重要意义。本研究对近5年(2019—2023年)来SAP治疗方面取得的最新进展进行综述,为SAP临床诊治理清思路。

基于降钙素原水平指导抗生素联合连续性血液净化治疗重症急性胰腺炎的效果

目的探讨基于降钙素原(PCT)监测水平指导应用抗生素联合连续性血液净化(CBP)对重症急性胰腺炎(SAP)患者预后转归及免疫内稳状态的影响。方法选取2020年2月至2022年6月赣州市人民医院收治的80例SAP患者作为研究对象,按照随机数字表法分为研究组与对照组,每组40例。入院后两组均采取常规干预、CBP,对照组在上述基础参照SAP诊治指南抗生素应用原则给予抗生素治疗,研究组每天监测PCT指导应用抗生素。比较两组预后转归效果、治疗情况、治疗前后免疫内稳状态相关指标水平。结果研究组治疗总有效率为90.00%,高于对照组的72.50%,差异有统计学意义(P<0.05)。研究组抗生素应用时间、CBP时间、住院时间均短于对照组,住院治疗费用少于对照组,差异有统计学意义(P<0.05)。治疗后,两组CD4^(+)、CD8^(+)水平及CD4^(+)/CD8^(+)均高于治疗前,白细胞介素-1(IL-1)、干扰素γ(IFN-γ)水平均低于治疗前,且研究组CD4^(+)、CD8^(+)水平及CD4^(+)/CD8^(+)均高于对照组,IL-1、IFN-γ水平均低于对照组,差异有统计学意义(P<0.05)。结论基于PCT监测水平指导应用抗生素联合CBP治疗SAP可缩短治疗时间,改善机体免疫内稳状态,增强治疗效果,有助于减轻家庭经济负担。

重症急性胰腺炎诱发胃黏膜剥脱大出血1例

急性胰腺炎(acutepancreatitis,AP)病情进展快、个体差异大、隐匿性强,常伴有胰腺脓肿、休克、多脏器功能衰竭等严重并发症,但AP所致的胃黏膜剥脱伴大出血在临床较罕见。本文回顾性分析1例因重症AP诱发胃黏膜剥脱并消化道出血的临床病例,探讨该病例的诊断、治疗及预后等,以期加强对重症AP罕见并发症的临床认识,并为其临床诊治提供参考。

通腑解毒汤联合常规西医治疗重症急性胰腺炎的效果

目的:探讨通腑解毒汤联合常规西医治疗重症急性胰腺炎(SAP)的临床效果。方法:选取2021年1月—2023年12月毕节市中医医院收治的65例SAP患者作为研究对象,按随机数表法分为对照组(n=33)及观察组(n=32)。对照组行常规西医治疗,观察组加用通腑解毒汤治疗,持续10 d。比较两组临床疗效、症状消失时间、血流动力学指标、炎症水平、急性生理与慢性健康状况(APACHEⅡ)评分、Marshall多脏器功能障碍(MODS)评分。结果:观察组总有效率高于对照组,差异有统计学意义(P<0.05)。观察组发热消失时间、腹痛消失时间、呕吐消失时间、血清淀粉酶复常时间及首次排便时间短于对照组,差异有统计学意义(P<0.05)。治疗后,观察组心率(HR)、血乳酸(BL)、白细胞介素-6(IL-6)、白细胞介素-8(IL-8)、超敏C反应蛋白(hs-CRP)、肿瘤坏死因子-α(TNF-α)低于对照组,平均动脉压(MAP)高于对照组,差异有统计学意义(P<0.05)。治疗后,观察组APACHEⅡ评分、MODS评分低于对照组,差异有统计学意义(P<0.05)。结论:通腑解毒汤联合常规西医治疗SAP患者效果显著,可加快体内炎症消退,纠正心率、血压异常,促进疾病症状消失。

乌司他丁联合生长抑素治疗重症急性胰腺炎的临床疗效分析

目的探究乌司他丁联合生长抑素治疗重症急性胰腺炎的临床疗效。方法便利选取山东省济南市章丘区中医医院于2019年6月-2023年9月收治的78例重症急性胰腺炎患者为研究对象,采用密闭信封法分为对照组和研究组,各39例。所有患者均采用常规治疗,对照组在此基础上使用生长抑素,研究组在对照组基础上静脉注射乌司他丁。对比两组临床疗效及不良反应发生率,检测肿瘤坏死因子-α、白细胞介素-6、C反应蛋白、淀粉酶、谷丙转氨酶、肌酐水平,并对比生活质量简表(World Health Organization Quality of Life-100,WHOQOL-100)评分。结果研究组治疗总有效率为97.44%,高于对照组,差异有统计学意义(χ^(2)=3.924,P=0.048)。治疗后,研究组各项血清指标水平低于对照组,差异有统计学意义(P<0.001)。两组不良反应发生率对比,差异无统计学意义(P>0.05)。治疗后,研究组WHOQOL-100评分高于对照组,差异有统计学意义(P<0.05)。结论重症急性胰腺炎患者应用乌司他丁联合生长抑素治疗效果显著,可提高治疗有效率,改善血清指标水平,用药安全性较高,从而提高患者生活质量。

蔡炳勤教授论重症急性胰腺炎的“膜原-三焦-卫气营血”病机轴

重症急性胰腺炎的治疗目前采用多学科综合治疗及护理模式,其中中医药在重症急性胰腺炎的不同病程阶段都发挥了积极的治疗作用。广东省名中医蔡炳勤教授在长期治疗重症急性胰腺炎的临床实践中,提出分“期”分“机”治疗原则,将其发病机理概况为“膜原-三焦-卫气营血”病机轴,为构建重症急性胰腺炎中医药治疗的“理法方药”体系奠定理论基础。

SAP患者鼻胃管肠内营养时机选择及肠源性感染指标表达水平的变化分析

目的 观察重症急性胰腺炎(SAP)患者给予鼻胃管肠内营养时机的选择及肠源性感染指标表达水平的变化.方法 选择2017年5月至2020年12月在邢台医学高等专科学校第二附属医院接受治疗的90例SAP患者作为研究对象.按随机数字表法将患者分为早期肠内营养组(45 例)和常规肠内营养组(45 例),于入院 48h内和 48h后给予鼻胃管肠内营养.比较两组治疗效果、治疗前和治疗 14d后的营养状况及肠源性感染指标的差异,并观察并发症发生情况.结果 与常规肠内营养组比较,治疗后早期肠内营养组计算机断层扫描严重指数(CTSI)评分(分:3.41±1.22 比 3.94±1.20)、Ranson评分(分:3.37±1.03 比 3.82±0.97)、急性生理学与慢性健康状况评分Ⅱ[APACHEⅡ(分):7.54±3.62 比 10.08±3.52]、C-反应蛋白[CRP(mg/L):5.88±1.03比 17.49±3.64]、降钙素原[PCT(μg/L):1.68±0.42 比 5.57±1.26]、白细胞计数[WBC(×10^(9)/L):9.31±1.24 比12.98±2.01]和内毒素(kU/L:0.28±0.08 比 0.66±0.21)均明显降低(均P<0.05),重症监护病房(ICU)住院时间(d:9.63±4.76 比 14.82±4.61)、住院时间(d:21.46±5.18 比 26.80±5.35)均明显缩短(均P<0.05),住院费用明显减少(万元:11.87±1.92 比13.59±2.47,P<0.05),多器官功能障碍综合征(MODS:13.33%比 42.22%)、肺炎(20.00%比 44.44%)、呼吸衰竭(8.89%比 33.33%)和胰腺感染(11.11%比 35.56%)等并发症发生率亦均明显降低(均P<0.05);前白蛋白(g/L:36.10±3.46 比 32.19±3.17,P<0.05)、白蛋白(g/L:0.29±0.04 比0.25±0.05,P<0.05)水平均明显升高.结论 对SAP患者早期给予肠内营养能有效改善营养状况,降低肠源性感染指标水平,并减少MODS、胰腺感染、呼吸衰竭、肺炎等的发生率,从而能促进患者恢复,缩短其ICU住院时间和住院时间,减少住院费用;加之鼻胃管肠内营养操作简单方便,置管费用低,患者耐受性高,可在临床推广应用.