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The serial treatment of necrotizing pancreatitis by MARPN (a). In the radiology department, the guidewire is inserted into the center of the necrotic mass, taking a line between the lower pole of the spleen, the splenic flexure of the colon, and the upper pole of the left kidney (b, c). Then in the operating room, the surgeon dilates the guidewire track using increasing diameter nephrectomy dilators, under X-ray control using the vertebral column and the position of a nasogastric tube as a reference point (d). Following multiple skunk procedures using a straight rigid nephroscope, the necrosis has largely been cleared and the necrotic cavity has collapsed around the 28-French chest drain (e); the tract will heal by granulation tissue on steady withdrawal then downsizing of the drain over several weeks as an outpatient
Source publication
Background:
Acute pancreatitis (AP) is defined as an acute inflammatory attack of the pancreas of sudden onset. Around 25% of patients have either moderately severe or severe disease with a mortality rate of 15-20%.
Purpose:
The aim of this article was to summarize the advances being made in the understanding of this disease and the important ro...
Citations
... A drenagem cirúrgica provou sua eficácia, principalmente em pseudocistos grandes e complicados. Logo, o tratamento de escolha depende do perfil individual do paciente.6 Complicações locais como sangramento no local do procedimento, infecção do cateter e vazamento do ducto pancreático podem ocorrer[10]. ...
As doenças hepáticas, de vias biliares e pancreáticas podem causar grande morbimortalidade. Nesses casos, o diagnóstico e o tratamento precoces são essenciais para reverter esse processo e melhorar o prognóstico. Apresentamos um caso clínico de um paciente masculino, 45 anos, etilista crônico, que foi internado, em estado geral grave, com coleções peripancreáticas (Balthazar E) sintomática com repercussão multissistêmica. Foi submetido ao tratamento minimamente invasivo, com duas drenagens percutâneas por abscessos intra-abdominais e terapia antimicrobiana de amplo espectro. Associado a isso, houve exame físico seriado, acompanhamento laboratorial e por imagem, culminando na resolução do quadro após 34 dias de internação hospitalar e sem complicações após a internação até o momento. Concluímos que a drenagem percutânea é uma boa opção para pacientes sépticos secundários à infecção por coleções peripancreáticas em um serviço com indisponibilidade de abordagem endoscópica. Utilizou-se o PUBMED como plataforma de pesquisa para a busca de referências dos últimos 5 anos e foi observada uma lacuna na literatura brasileira recente acerca deste tema, o que fomenta a discussões e novas pesquisas futuras.
... In addition to these forms, Dellinger E.P. et al. (2012) distinguish critical AP characterized by persistent organ failure and infected (peri-)pancreatic necrosis [4]. About 15-25 % of AP patients suffer from a moderate or severe disease with 8-20 % mortality rate [1,5,6]. The high catabolic activity with the negative nitrogen balance during severe AP [7,8] is associated with a local and systemic inflammation; hence, a timely and adequate nutritive support in this group of patients is essential. ...
... where n is the sample size (n = 64); Z (1.96) is the normalized deviate at 95 % confidence probability; p is the incidence of pancreatic necrosis (20 %) [6]; q = (100 − p); e is the allowable error of sample, which is 9.8 % that corresponds to ordinary reliability [18]. Raw data were statistically processed using SPSS-26 software package (IBM, USA). ...
... Analysis of subgroups of patients only with severe or predictably severe AP has shown that mortality was lower by more than 80 % in the EF group [10,[34][35][36]. The advantage of EF is its ability to support the intestinal barrier integrity diminishing bacteria and bacterial endotoxin entering the systemic blood flow [6]. EF stimulates intestinal motility and increases its blood flow [37]. ...
OBJECTIVE: Studying the influence of early nasogastric (NG) and nasojejunal (NJ) probe feeding in patients with predictors of severe acute pancreatitis on the course and outcome of the disease. MATERIALS AND METHODS: An open randomized controlled study was performed in Neftyanik Occupational Healthcare Facility ICU. 64 patients with predictors of severe acute pancreatitis (APACHE II > 8, CRP > 150 mg/l, SOFA > 2) randomized by the envelope method for early (the first 24 hrs.) nasogastic or nasojejunal feeding. The standard polymer feeding formula enriched with dietary fibers was administered during the first 5 (five) days taking into account its tolerability. Raw data were statistically processed using SPSS-26 software. RESULTS: Comparison of the NG (n = 33) vs. NJ (n = 31) groups produced the following results: the duration (days) of treatment in the hospital was 21 (12; 42) vs. 24 (11; 35), p = 0.715; in ICU — 4 (2; 20) vs. 4 (3; 13), p = 0.803; mechanical ventilation (MV) — 1 (1; 3) vs. 1 (1; 1), p = 0.124; mortality — OR 0.830 (95 % CI 0.201–3.422), p = 0.796; severity (moderately severe or severe) — OR 1.29 (95 % CI 0.483–3.448), p = 0.611; number of patients subjected to surgery during the first period of the disease — OR 0.774 (95 % CI 0.243–2.467), p = 0.665; and second period of the disease — OR 1.682 (95 % CI 0.623–4.546), p = 0.305. CONCLUSIONS: No difference has been found between the groups of patients with severe disease predictors, who received early nasogastric or nasojejunal tube feeding using standard polymer formula with dietary fibers during early acute pancreatitis, as regards duration of treatment in the hospital, in ICU, numbers of mechanically ventilated patients, patients operated during the first and second disease periods, disease severity or mortality.
... szerint a konzervatív kezeléstől a szemikonzervatívon keresztül kell lépésről lépésre haladni a sebészi beavatkozásig [1][2][3][4][5][6][7][8][9][10][11][12]. A műtét időpontját lehetőség szerint a demarkált pancreasnecrosis (walled-off pancreatic necrosis, WOPN) kialakulására kell időzíteni [1,3,5,6,8,9,11,[13][14][15][16][17][18][19][20][21][22]. A sebészet általános elveinek megfelelően lehetőleg minimálisan invazív módszereket (például laparoszkópia) tanácsos alkalmazni [1, 2, 5-11, 12-14, 18-21, 23]. ...
Az akut pancreatitis sebészi kezelése az utóbbi időkben jelentősen megváltozott. A sürgősségi műtétek indikációja és sebészi technikája alapvetően hasonló a korábbi gyakorlathoz, azonban újabb indikációs terület jelent meg. Az abdominalis kompartment szindróma sürgős műtéti indikációt képez, ha a konzervatív és szemikonzervatív kezelés eredménytelen. Ilyenkor napjainkban a dekompressziós laparotomia és a negatívnyomás-terápiával kombinált nyitotthas-kezelés javasolt. A hagyományos sebészi necrosectomia helyett a minimálisan invazív sebészi kezelések terjedtek el, melyek csak a betegség késői stádiumában kialakuló, fertőzött, demarkált pancreasnecrosis esetén javasoltak. Napjainkban a demarkált necrosis első vonalbeli kezelése az endoszkópos endoluminalis transgastricus necrosectomia, de kiterjedt esetekben, és ha a necroticus üreg fala túl vastag, valamint ha cholecystectomia is szükséges, a laparoszkópos vagy nyitott transgastricus necrosectomia indokolt. A szerzők elemzik a sebészi kezelésben beállt változásokat, kitérnek a javallatok és a műtéti technika kérdéseire is. Orv Hetil. 2024; 165(15): 563–567.
... Acute pancreatitis (AP) is an acute inflammation of the pancreas and one of the leading global causes of hospitalization for gastrointestinal complications [1]. Heckler et al. indicated that approximately 20% of AP cases usually progress to severe pancreatitis, leading to pancreatic necrosis and multi-organ failure; hence, the reason for the continued increase in mortality rate is currently estimated to be 40% [2]. For instance, pancreatic necrosis is mainly characterized by fluid loss due to hypoperfusion, splanchnic vasoconstriction, and reduced blood flow into the pancreas [3]. ...
Introduction
Acute pancreatitis poses a significant health risk due to the potential for pancreatic necrosis and multi-organ failure. Fluid resuscitation has demonstrated positive effects; however, consensus on the ideal intravenous fluid type and infusion rate for optimal patient outcomes remains elusive.
Methods
A comprehensive literature search was conducted using PubMed, Embase, the Cochrane Library, Scopus, and Google Scholar for studies published between 2005 and January 2023. Reference lists of potential studies were manually searched to identify additional relevant articles. Randomized controlled trials and retrospective studies comparing high (≥ 20 ml/kg/h), moderate (≥ 10 to < 20 ml/kg/h), and low (5 to < 10 ml/kg/h) fluid therapy in acute pancreatitis were considered.
Results
Twelve studies met our inclusion criteria. Results indicated improved clinical outcomes with low versus moderate fluid therapy (OR = 0.73; 95% CI [0.13, 4.03]; p = 0.71) but higher mortality rates with low compared to moderate (OR = 0.80; 95% CI [0.37, 1.70]; p = 0.55), moderate compared to high (OR = 0.58; 95% CI [0.41, 0.81], p = 0.001), and low compared to high fluids (OR = 0.42; 95% CI [0.16, 1.10]; P = 0.08). Systematic complications improved with moderate versus low fluid therapy (OR = 1.22; 95% CI [0.84, 1.78]; p = 0.29), but no difference was found between moderate and high fluid therapy (OR = 0.59; 95% CI [0.41, 0.86]; p = 0.006).
Discussion
This meta-analysis revealed differences in the clinical outcomes of patients with AP receiving low, moderate, and high fluid resuscitation. Low fluid infusion demonstrated better clinical outcomes but higher mortality, systemic complications, and SIRS persistence than moderate or high fluid therapy. Early fluid administration yielded better results than rapid fluid resuscitation.
... Acute pancreatitis (AP) is a sudden onset inflammatory condition of the pancreas that is associated with an overall mortality rate of 3-5 % [1,2]. Most patients with AP experience mild disease with a self-limited course. ...
Acute pancreatitis (AP) is a sudden-onset inflammatory disease of the pancreas. The severity of AP is classified into mild, moderate, and severe categories based on the presence and persistence of organ failure. Severe acute pancreatitis (SAP) can be associated with significant morbidity and mortality. It requires early recognition for appropriate timely management. Prognostic scores for predicting SAP incorporating many clinical, laboratory, and radiological parameters have been developed in the past. However, all of these prognostic scores have low positive predictive value for SAP and some of these scores require >24 h for assessment. There is a need to develop biomarkers that can accurately identify patients at risk for SAP early in the course of the presentation. In this review, we aim to provide a summary of the most commonly utilized prognostic scores for AP and discuss future directions.
... Despite advancements in our understanding of the pathogenesis of AP pathogenesis, the prevalence of the disease continues to increase each year, with ~20% of patients progressing to severe AP (SAP). SAP can subsequently evolve into a systemic inflammatory response and a multiple organ dysfunction syndrome, ultimately resulting in considerably high mortality rates with a range of 20-40% (4)(5)(6)(7). At present, the primary emphasis in the management of AP is on providing supportive care, including fluid resuscitation, pain management and parenteral nutrition support (4,8,9). ...
Calcium overload, a notable instigator of acute pancreatitis (AP), induces oxidative stress and an inflammatory cascade, subsequently activating both endogenous and exogenous apoptotic pathways. However, there is currently lack of available pharmaceutical interventions to alleviate AP by addressing calcium overload. In the present study, the potential clinical application of liposome nanoparticles (LNs) loaded with 1,2-bis(2-aminophenoxy)ethane-N,N,N′,N′-tetraacetic acid tetrakis (acetoxymethyl ester) (BAPTA-AM), a cell-permeant calcium chelator, was investigated as a therapeutic approach for the management of AP. To establish the experimental models in vitro, AR42J cells were exposed to high glucose/sodium oleate (HGO) to induce necrosis, and in vivo, intra-ductal taurocholate (TC) infusion was used to induce AP. The findings of the present study indicated that the use of BAPTA-AM-loaded LN (BLN) effectively and rapidly eliminated excessive Ca²⁺ and reactive oxygen species, suppressed mononuclear macrophage activation and the release of inflammatory cytokines, and mitigated pancreatic acinar cell apoptosis and necrosis induced by HGO. Furthermore, the systemic administration of BLN demonstrated promising therapeutic potential in the rat model of AP. Notably, BLN significantly enhanced the survival rates of rats subjected to the TC challenge, increasing from 37.5 to 75%. This improvement was attributed to the restoration of pancreatic function, as indicated by improved blood biochemistry indices and alleviation of pancreatic lesions. The potential therapeutic efficacy of BLN in rescuing patients with AP is likely attributed to its capacity to inhibit oxidative stress, prevent premature activation of zymogens and downregulate the expression of TNF-α, IL-6 and cathepsin B. Thus, BLN demonstrated promising value as a novel therapeutic approach for promptly alleviating the burden of intracellular Ca²⁺ overload in patients with AP.
... Therefore, we suggest that a decrease in Abbreviations listed in Tables 1 and 2. urine volume within a few days of SAP onset is important for determining the deterioration of kidney injury and initiation of blood purification. In addition, SAP progresses to multiple organ dysfunction a few days after the onset of acute pancreatitis (20). Systemic deterioration accompanied by kidney injury was assessed using the prognostic factor score and LIS in the present study, which provided useful information for the initiation of PMMA-CHD. ...
Objective We previously reported the successful outcomes in severe acute pancreatitis (SAP) after continuous hemodialysis using a polymethylmethacrylate hemofilter (PMMA-CHD). The present study makes informative suggestions regarding the initiation and termination of PMMA-CHD.
Methods We retrospectively studied 63 patients with SAP admitted to the intensive-care unit between January 1, 2011, and December 31, 2022, including 30 who received PMMA-CHD therapy for renal dysfunction. Statistical significance was evaluated using a multiple logistic regression analysis for severity scores, prognostic factor scores in the Japanese severity criteria, the Kidney Disease: Improving Global Outcomes (KDIGO) stage, and the lung injury score (LIS).
Results At the onset of blood purification therapy using PMMA-CHD, a significant increase in the KDIGO stage was shown, with a cutoff value of 2.0. The prognostic factor score and LIS at the start of blood purification therapy were significantly high, with a cutoff value of 3.0. Analyses of severity scores, the KDIGO stage, and the LIS before the start of PMMA-CHD were also increased significantly, with cutoff values of +2.0, +1.0, and +3.0, respectively. Furthermore, on analyses of improvements in values after starting PMMA-CHD, the value of KDIGO staging significantly decreased, and the cutoff value was −2.0. The prognostic factor score was also significantly decreased, with a cutoff value of −2.0.
Conclusion Prognostic factor scores of the Japanese severity criteria and LIS, as well as the KDIGO stage, are valuable indicators for determining the start and end of PMMA-CHD therapy.
... WON can cause pain and mechanical compression of adjacent organs and structures, leading to infection, sepsis, and multiorgan failure [5]. Heckler et al. revealed that there are two phases of mortality, and although the primary cause of death in the first week is multiorgan failure, most subsequent deaths are due to local pancreatic necrosis [17]. Therefore, the management of local complications of AP is crucial. ...
A 54-year-old man was admitted for fever and dyspnea. He presented with severe COVID-19 pneumonia and elevated amylase and lipase levels. He received treatment for COVID-19 and possible acute pancreatitis (AP). Although pneumonia and amylase levels improved, a high-grade fever persisted. On day 39, abdominal CT revealed heterogenous liquid and non-liquid components with a well-defined wall around the pancreas, and he was diagnosed with infected walled-off necrosis (WON) after AP. It was concluded to be associated with COVID-19 because there were no identifiable causes, such as alcohol consumption, gallstones, or other viral infections. The necrotic collection and fever improved after endoscopic transgastric drainage and necrosectomy. SARS-CoV-2 is becoming recognized as a new etiological infectious factor for AP, and COVID-19-associated AP shows higher severity and mortality. Clinicians should evaluate COVID-19 patients for concomitant AP, and if it is present, they should carefully monitor the development of local complications, including WON.
... Com incidência crescente, inclusive em crianças, gestantes e idosos, a PA é uma aproximadamente 20-30%. Em uma revisão sistemática e metanálise, foi evidenciado que a mortalidade em pacientes com necrose infectada, associada a falência orgânica era de aproximadamente 35,2%, comparada a 19,8% em casos de necrose estéril associada a falência orgânica e 1,4% em necrose sem falência orgânica (HECKLER et al., 2020;BEYER et al., 2022). ...
... Dessa forma, baseado nisso, temos que a principal indicação de abordagem seria a presença de necrose pancreática, associada a um contexto de piora clínica do paciente. O tempo de intervenção é uma informação importante na indicação cirúrgica, existindo uma regra geral de abordagem 4 semanas após o início dos sintomas, de forma a obter melhor delimitação do tecido necrótico, embora isso nem sempre seja possível (HECKLER et al., 2020). ...
... A infecção da necrose pancreática e peripancreática ocorre em cerca de 20-40% dos pacientes com PA grave e está associada ao agravamento das disfunções orgânicas. Em uma revisão sistemática e metanálise totalizando 6.970 pacientes, a taxa de mortalidade em pacientes com necrose infectada e falência de órgãos foi de 35,2%, em comparação com 19,8% para necrose estéril com falência de órgãos e 1,4% para necrose infectada sem falência de órgãos(LEPPÄNIEMI et al., 2019;HECKLER et al., 2020).Brazilian Journal of Health Review, Curitiba, v. 6, n. 5, p. 23678-23685, sep./oct., 2023 5 SINTOMATOLOGIA E DIAGNÓSTICO Em grande parte dos casos a PA se manifesta como uma dor abdominal, descrita em localização epigástrica persistente e intensa, frequentemente irradiando para as costas com início agudo. Além disso, é comum em cerca de até 80% dos casos a presença de vômitos e náuseas, associado a distensão abdominal, febre, agitação e queda do nível de consciência em casos de desidratação acentuada e complicações (SZATMARY et al., 2022). ...
A Pancreatite Aguda (PA) é uma inflamação súbita do pâncreas causada pelas próprias enzimas pancreáticas, resultando em sintomas agudos que geralmente desaparecem quando a glândula se recupera. Os principais fatores desencadeantes incluem cálculos biliares e consumo excessivo de álcool. O diagnóstico é baseado em critérios como dor abdominal súbita, níveis elevados de amilase ou lipase no sangue e exames de imagem. A incidência da PA está aumentando globalmente, afetando pessoas de todas as idades, incluindo crianças, gestantes e idosos. A PA moderadamente grave pode causar morbidade significativa e levar à falência persistente. Os casos de PA estão se tornando mais comuns em todo o mundo, com uma estimativa de 34 casos por 100.000 pessoas por ano. Os sintomas típicos da PA incluem dor abdominal intensa na região epigástrica, muitas vezes irradiando para as costas, acompanhada de vômitos, náuseas, distensão abdominal, febre e outras manifestações clínicas. O diagnóstico envolve a investigação das possíveis causas, como cálculos biliares, obesidade, consumo de álcool e medicamentos que podem desencadear a doença.Em cerca de 20% dos casos, ocorre necrose pancreática, com um risco significativo de infecção associada. A mortalidade é maior em casos de necrose infectada e falência orgânica. A decisão de intervenção cirúrgica depende da presença de necrose pancreática sintomática e piora clínica do paciente. Geralmente, a cirurgia é considerada após 4 semanas do início dos sintomas para melhor avaliação do tecido necrótico.
... El tratamiento quirúrgico se recomienda entre la tercera o cuarta semana de evolución 38,123,124 . La necrosectomía se realiza usando la técnica de preservación de órgano con disección roma, para minimizar el riesgo de sangrado, fístula o remoción de tejido vivo 125 . Las técnicas quirúrgicas incluyen abordaje laparoscópico, necrosectomía retroperitoneal de mínima invasión y necrosectomía retroperitoneal; en adultos, ninguna técnica ha mostrado ser mejor que otra 23,125 . ...
