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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 pancreatitis: A systematic review. World J Gastroenterol 2007;13(39):5253-5260. ETIOLOGY. Meta analysis 20 studies, >100 patients/study.

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INCIDENCE OF ACUTE PANCREATITIS

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  1. 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

  2. ETIOLOGY Meta analysis 20 studies, >100 patients/study Lankisch, Dig Dis Sci 2001.

  3. NATURAL HISTORY Study flowchart: natural history of 532 patients diagnosed with a first attack of acute pancreatitis Lankisch et al, Am J Gastroenterol 2009; 104:2797–2805;.

  4. RELAPSE RATE Relapse rate after the first attack of acute pancreatitis according to its etiology Lankisch et al, Am J Gastroenterol 2009; 104:2797–2805;.

  5. SEVERITY OF ACUTE PANCREATITIS Olah A, Romics Jr. L. Early enteral nutrition in acute pancreatitis – benefits and limitations. Langenbecks Arch Surg 2008; Mortality < 1% Infected necrosis (30-40%) ↓ Mortality ~ 30%

  6. THE PROGNOSTIC ROLE OF ABDOMINAL PERFUSION PRESSURE IN SAP Admission APP vs. APACHE II score in the prediction of mortality in patients with SAP. Al-Bahrani AZ et al. Pancreas 2008; 36:39-43

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

  8. PHARMACOLOGICAL TREATMENT IN ACUTE PANCREATITIS Overview of drugs tested in animal experimental models and clinical trials Bang UC, Semb S, Nojgaard C, Bendtsen F. Pharmacological approach to acute pancreatitis. World J Gastroenterol 2008;14(19):2968-2976.

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

  10. ERCP – therapeutic indications High mortality rate in patients with biliary sepsis with impacted stones Biliary obstruction, dilated bile duct, cholangitis – urgent ERCP/ES and stone extraction Neoptolemos, Lancet 1988;2:979-983 Folsch, N Engl J Med 1997;336:237-242 Kozark, GastrointestEndosc 2002;56(Suppl):231-236

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

  12. EARLY ERCP vs. CONSERVATIVE THERAPY Van Santvoort et al. Ann Surg 2009; 250(1):68-75.

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

  14. IS NUTRITION SO IMPORTANT? • Little influence on nutritional status and metabolism MILD AP • Increased energy expenditure • Hypermetabolism • Protein catabolism (negative nitrogen balance up to 40 g/day) • Malnutrition SEVERE AP Meier R, Ockenga J, Pertkiewicz M, Pap A, Milinic N, MacFie J. ESPEN guidelines on enteral nutrition: Pancreas. Clin Nutr 2006;25:275-284.

  15. ESPEN GUIDELINES 2006. MILD AP • No need for enteral nutrition • Normal food after 5 – 7 days • If oral food not tolerated – intrajejunal supply after 5 days • SEVERE AP • Early enteral nutrition if feasible • Parenteral nutrition supplement if needed • Oral food intake as soon as possible Meier R, Ockenga J, Pertkiewicz M, Pap A, Milinic N, MacFie J. ESPEN guidelines on enteral nutrition: Pancreas. Clin Nutr 2006;25:275-284.

  16. Olah A, Romics Jr. L. Early enteral nutrition in acute pancreatitis – benefits and limitations. Langenbecks Arch Surg 2008; ENTERAL NUTRITION vs. TOTAL PARENTERAL NUTRITION

  17. Marik PE. Current Opinion in Critical Care 2009; 15:131-138 ENTERAL NUTRITION vs. PARENTERAL NUTRITION Effect of route of nutritional support on the acquisition of new infections

  18. ENTERAL NUTRITION vs. TOTAL PARENTERAL NUTRITION LOWER INCIDENCE • Infection • Surgical intervention • Lenght of hospital stays No significant difference in mortality rates and noninfective complications Olah A, Romics Jr. L. Early enteral nutrition in acute pancreatitis – benefits and limitations. Langenbecks Arch Surg 2008;

  19. FREQUENCY OF “EN” ADMINISTRATION 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.

  20. Intrajejunal administration Standard formula If not tolerated Peptid-based formula Meier R, Ockenga J, Pertkiewicz M, Pap A, Milinic N, MacFie J. ESPEN guidelines on enteral nutrition: Pancreas. Clin Nutr 2006;25:275-284.

  21. Comparison of different enteral nutrition formulations Pooled estimates and sensitivity analysis Funnel plot of included trials Petrov MS et al. British Journal of Surgery 2009; 96:1243-52

  22. STUDY CONCLUSIONS Neither the supplementation of enteral nutrition with probiotics nor the use ofimmunonutrition significantly improves the clinical outcomes. The use of polymeric vs. (semi)elemental formulation leads to no significantlyhigher risk offeeding 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

  23. PROBIOTIC PROPHYLAXIS IN PREDICTED SEVERE ACUTE PANCREATITIS Pooled Kaplan-Meier time-to-event analysis for mortality in the first 90 days after randomization. Besselink MGH et al. Lancet 2008; 371:651-59

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

  25. 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)

  26. Prophylactic Antibiotics Cannot Reduce Infected Pancreatic Necrosis and Mortality in Acute Necrotizing Pancreatitis: Evidence From a Meta-Analysis of Randomized Controlled Trials Yu Bai, M.D., Jun Gao, Duo-Wu Zou, Zhao-Shen Am J Gastroenterol 2008;103:104–110

  27. RESULTS 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)

  28. 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)

  29. Is prophlylactic use of antibiotics protective in severe acute pancreatitis? Pooled Meta-analysis of prophylactic antibiotics versus placebo/no intervention effect on mortality. Jafri NS et al. The American Journal of Surgery 2009; 197:806-813

  30. 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)

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

  32. 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%

  33. MINIMALLY INVASIVE TECHNIQUES IN PANCREATIC NECROSIS Navaneethan U, Vege SS, Chari ST, Bron TH; Pancreas 2009; 38:867-875

  34. PERCUTANEOUS DRAINAGE FOR PANCREATIC NECROSIS Navaneethan U, Vege SS, Chari ST, Bron TH; Pancreas 2009; 38:867-875

  35. ENDOSCOPIC THERAPY FOR PANCREATIC NECROSIS Navaneethan U, Vege SS, Chari ST, Bron TH; Pancreas 2009; 38:867-875

  36. LAPAROSCOPIC TECHNIQUE FOR PANCREATIC NECROSIS Navaneethan U, Vege SS, Chari ST, Bron TH; Pancreas 2009; 38:867-875

  37. RETROPERITONEAL APROACH FOR PANCREATIC NECROSIS Navaneethan U, Vege SS, Chari ST, Bron TH; Pancreas 2009; 38:867-875

  38. 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

  39. 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 ?

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

  41. 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

  42. ABDOMINAL COMPARTMENT SYNDROME (ACS) Comparison of complications and outcome between patients with and without ACS Chen H, Li F, Sun JB, Jia JG. World J gastroenterol 2008; 14(22):3541-8

  43. PREVENTION OF IAH in patients with severe AP Colloids aim: reduce overhydration Judicious use of NaCl Albumin De Waele JJ, Leppäniemi AK Intra-Abdominal Hyprtension in Acute Pancreatitis. World J Surg 2009; 33:1128-1133

  44. NONSURGICAL TREATMENT OF IAH in patients with severe AP Hemodialysis aim: reduce IAP Percutaneous ascites drainage NG tube Neuromuscular blockers (short-term use) De Waele JJ, Leppäniemi AK Intra-Abdominal Hyprtension in Acute Pancreatitis. World J Surg 2009; 33:1128-1133

  45. SURGICAL DECOMPRESSION OF IAH in patients with severe AP • 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) De Waele JJ, Leppäniemi AK. World J Surg 2009; 33:1128-1133

  46. SURGICAL DECOMPRESSION OF IAH in patients with severe AP • Is it safe ??? • retroperitoneal hemorrhage • prolonged course • multiple reoperations • high risk of complications • subcutaneous fasciotomy – safest De Waele JJ, Leppäniemi AK. World J Surg 2009; 33:1128-1133

  47. EARLY ICU RATIONALE THERAPY & = EARLY RECOGNITION -SEVERITY SIGNS Pharmacological prevention still impossible Bang UC, Semb S, Nojgaard C, Bendtsen F. Pharmacological approach to acute pancreatitis. World J Gastroenterol 2008;14(19):2968-2976.

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