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What's new in the management of severe acute pancreatitis?

Mallédant Y, Malbrain ML, Reuter DA - Intensive Care Med (2015)

View Article: PubMed Central - PubMed

Affiliation: Réanimation Chirurgicale, Service d'Anesthésie Réanimation 1, Hôpital Pontchaillou, 35033, Rennes, France. yannick.malledant@chu-rennes.fr.

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In a recent meta-analysis including eight randomized controlled studies and 381 patients, enteral nutrition compared with parenteral nutrition decreased infectious complications and mortality... Recently, in less severe illness (APACHE II score 11; 6 % of the patients with multiple organ failure), a trial did not show the superiority of enteral nutrition within 24 h compared with oral diet after 72 h, in reducing the rate of infection or death... However, exclusive gastric feeding succeeds with the delivery of nutritional targets in 90 % of patients... The type of dietary mixture used did not appear decisive, and the effect of immunonutrition, glutamine supplementation and probiotics has not been demonstrated (Cochrane Database Syst Rev Mar 23;3:CD010605)... Infected necrosis occurs in 40–70 % of patients in the second or third week of the illness and is the leading cause of late mortality... More conservative intervention than surgical necrosectomy now predominates... A step-up approach of percutaneous drainage followed, if necessary, by a minimally invasive surgical necrosectomy significantly reduces the rate of major complications and mortality by 29 % compared with open surgery... Moreover, postponement of a surgical necrosectomy provides an opportunity for acute collections to become walled-off and liquefied... A randomized study with a very small number of patients requiring secondary pancreatic debridement found endoscopic transgastric necrosectomy to be superior to surgical necrosectomy with respect to the overall rate of major complications or mortality (20 vs. 80 %)... However, endoscopic ultrasound is clearly superior, with a sensitivity and specificity greater than 90 % in the detection of bile duct stones... A recent Cochrane Database search found no benefit from early ERCP with respect to mortality and local complications, claiming that ERCP is not needed in patients without evidence of biliary obstruction (Cochrane Database Syst Rev May 16;5:CD009779)... A subcutaneous linea alba fasciotomy (SLAF) can be performed by utilizing three short horizontal skin incisions with the peritoneum closed avoiding a true open abdomen... SLAF needs further clinical evaluation and does result in a giant midline hernia with associated need for surgery at a later stage.

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Related in: MedlinePlus

Management of severe pancreatitis. BMI body mass index, ATB antibiotics, ERCP endoscopic retrograde cholangiopancreatography, ACS abdominal compartment syndrome, PCD percutaneous (or endoscopic) drainage
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Fig1: Management of severe pancreatitis. BMI body mass index, ATB antibiotics, ERCP endoscopic retrograde cholangiopancreatography, ACS abdominal compartment syndrome, PCD percutaneous (or endoscopic) drainage

Mentions: The original Ranson criteria from 1974, last modified in 2012, have been followed by several new and in part much more complex scoring systems; however, these have only increased diagnostic performance modestly (AUC from 0.57 to 0.74) [3]. Recent findings suggest that the presence of under- or overweight, development or persistence of organ failure, and assessment of biomarkers, such as cytokine levels might help to further improve identification of high-risk patients [4, 5] (Fig. 1).


What's new in the management of severe acute pancreatitis?

Mallédant Y, Malbrain ML, Reuter DA - Intensive Care Med (2015)

Management of severe pancreatitis. BMI body mass index, ATB antibiotics, ERCP endoscopic retrograde cholangiopancreatography, ACS abdominal compartment syndrome, PCD percutaneous (or endoscopic) drainage
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4582073&req=5

Fig1: Management of severe pancreatitis. BMI body mass index, ATB antibiotics, ERCP endoscopic retrograde cholangiopancreatography, ACS abdominal compartment syndrome, PCD percutaneous (or endoscopic) drainage
Mentions: The original Ranson criteria from 1974, last modified in 2012, have been followed by several new and in part much more complex scoring systems; however, these have only increased diagnostic performance modestly (AUC from 0.57 to 0.74) [3]. Recent findings suggest that the presence of under- or overweight, development or persistence of organ failure, and assessment of biomarkers, such as cytokine levels might help to further improve identification of high-risk patients [4, 5] (Fig. 1).

View Article: PubMed Central - PubMed

Affiliation: Réanimation Chirurgicale, Service d'Anesthésie Réanimation 1, Hôpital Pontchaillou, 35033, Rennes, France. yannick.malledant@chu-rennes.fr.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

In a recent meta-analysis including eight randomized controlled studies and 381 patients, enteral nutrition compared with parenteral nutrition decreased infectious complications and mortality... Recently, in less severe illness (APACHE II score 11; 6 % of the patients with multiple organ failure), a trial did not show the superiority of enteral nutrition within 24 h compared with oral diet after 72 h, in reducing the rate of infection or death... However, exclusive gastric feeding succeeds with the delivery of nutritional targets in 90 % of patients... The type of dietary mixture used did not appear decisive, and the effect of immunonutrition, glutamine supplementation and probiotics has not been demonstrated (Cochrane Database Syst Rev Mar 23;3:CD010605)... Infected necrosis occurs in 40–70 % of patients in the second or third week of the illness and is the leading cause of late mortality... More conservative intervention than surgical necrosectomy now predominates... A step-up approach of percutaneous drainage followed, if necessary, by a minimally invasive surgical necrosectomy significantly reduces the rate of major complications and mortality by 29 % compared with open surgery... Moreover, postponement of a surgical necrosectomy provides an opportunity for acute collections to become walled-off and liquefied... A randomized study with a very small number of patients requiring secondary pancreatic debridement found endoscopic transgastric necrosectomy to be superior to surgical necrosectomy with respect to the overall rate of major complications or mortality (20 vs. 80 %)... However, endoscopic ultrasound is clearly superior, with a sensitivity and specificity greater than 90 % in the detection of bile duct stones... A recent Cochrane Database search found no benefit from early ERCP with respect to mortality and local complications, claiming that ERCP is not needed in patients without evidence of biliary obstruction (Cochrane Database Syst Rev May 16;5:CD009779)... A subcutaneous linea alba fasciotomy (SLAF) can be performed by utilizing three short horizontal skin incisions with the peritoneum closed avoiding a true open abdomen... SLAF needs further clinical evaluation and does result in a giant midline hernia with associated need for surgery at a later stage.

No MeSH data available.


Related in: MedlinePlus