-
Olaf J Bakker,
Hjalmar van Santvoort, Marc G H Besselink,
Marja A Boermeester,
Casper van Eijck,
Kees Dejong,
Harry van Goor,
Sijbrand Hofker,
Usama Ahmed Ali,
Hein G Gooszen,
Thomas L Bollen
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVE: In the revised Atlanta classification of acute pancreatitis, the term necrotising pancreatitis also refers to patients with only extrapancreatic fat necrosis without pancreatic parenchymal necrosis (EXPN), as determined on contrast-enhanced CT (CECT). Patients with EXPN are thought to have a better clinical outcome, although robust data are lacking. METHODS: A post hoc analysis was performed of a prospective multicentre database including 639 patients with necrotising pancreatitis on contrast-enhanced CT. All CECT scans were reviewed by a single radiologist blinded to the clinical outcome. Patients with EXPN were compared with patients with pancreatic parenchymal necrosis (with or without extrapancreatic necrosis). Outcomes were persistent organ failure, need for intervention and mortality. A predefined subgroup analysis was performed on patients who developed infected necrosis. RESULTS: 315 patients with EXPN were compared with 324 patients with pancreatic parenchymal necrosis. Patients with EXPN less often suffered from complications: persistent organ failure (21% vs 45%, p<0.001), persistent multiple organ failure (15% vs 36%, p<0.001), infected necrosis (16% vs 47%, p<0.001), intervention (18% vs 57%, p<0.001) and mortality (9% vs 20%, p<0.001). When infection of extrapancreatic necrosis developed, outcomes between groups were equal (mortality with infected necrosis: EXPN 28% vs pancreatic necrosis 18%, p=0.16). CONCLUSION: EXPN causes fewer complications than pancreatic parenchymal necrosis. It should therefore be considered a separate entity in acute pancreatitis. Outcome in cases of infected necrosis is similar.
Gut 07/2012; · 10.11 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The management of infected peripancreatic or pancreatic necrosis in patients with severe pancreatitis has changed considerably
in recent years. This review discusses the recent literature on prevention, detection, and management of infected necrosis.
Though antibiotics, probiotics, and enteral nutrition have been tried to prevent infected necrosis, only enteral nutrition
has consistently proven to be effective. Antibiotics and probiotics have not shown a consistent beneficial effect on outcome.
Enteral nutrition reduced infectious complications and mortality in severe pancreatitis, compared with parenteral nutrition.
The detection of infection of pancreatic necrosis is important for clinical decision making. Fine-needle aspiration may be
used to confirm suspected infection, but if its results will not change clinical decisions, it should be omitted, as it may
even introduce infection. Minimally invasive surgical, radiologic, or endoscopic intervention is increasingly being applied.
In the absence of level 1 evidence, local expertise dictates which type of intervention is applied.
Current Gastroenterology Reports 04/2012; 11(2):104-110.
-
Marc G H Besselink
HPB 12/2011; 13(12):831-2. · 1.60 Impact Factor
-
Marc G H Besselink
Digestive and Liver Disease 06/2011; 43(6):421-2. · 3.05 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Bacterial translocation (BT) is suspected to play a major role in the development of infections in surgical patients. However, the clinical association between intestinal barrier dysfunction, BT, and septic morbidity has remained unconfirmed. The objective of this study was to study BT in patients undergoing major abdominal surgery and the effects of probiotics, selective decontamination of the digestive tract (SDD), and standard treatment on intestinal barrier function. In a randomized controlled setting, 30 consecutive patients planned for elective pylorus-preserving pancreaticoduodenectomy (PPPD) were allocated to receive perioperatively probiotics, SDD, or standard treatment. To assess intestinal barrier function, intestinal fatty acid-binding protein (mucosal damage) and polyethylene glycol recovery (intestinal permeability) in urine were measured perioperatively. BT was assessed by real-time polymerase chain reaction and multiplex ligation-dependent probe amplification (MLPA) in mesenteric lymph nodes (MLNs) harvested early (baseline control) and at the end of surgery ("end-of-surgery" MLNs, after 3h in PPPD patients). Polymerase chain reaction detected bacterial DNA in 18 of 27 end-of-surgery MLNs and in 13 of 23 control MLNs (P = 0.378). Probiotics and SDD had no significant effect on the number of positive MLNs or the change in bacterial DNA during operation. Multiplex ligation-dependent probe amplification analysis showed significantly increased expression of only 4 of 30 inflammatory mediator-related genes in end-of-surgery compared with early sampled MLN (P < 0.05). Polyethylene glycol recovery was unaffected by operation, probiotics and SDD as compared with standard treatment. Intestinal fatty acid-binding protein levels were increased shortly postoperatively only in patients treated with SDD (P = 0.02). Probiotics and SDD did not influence BT, intestinal permeability, or inflammatory mediator expression. Bacterial translocation after abdominal surgery may be part of normal antigen-sampling processes of the gut.
Shock (Augusta, Ga.) 01/2011; 35(1):9-16. · 2.87 Impact Factor
-
Surgical Endoscopy 04/2010; 25(1):331-2. · 4.01 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: One of the greatest challenges facing those treating pancreatic disease is the optimum treatment of infected pancreatic necrosis
(IPN). IPN may consist of either infected necrotic pancreatic tissue and/or infected peripancreatic fat necrosis. Despite
many improvements in management, the treatment algorithm for IPN remains for the most part defined by “expert opinion” rather
than based on data from randomized controlled trials (Nieuwenhuijs et al. 2003; Werner et al. 2005). In the past decade, the
most important developments in the management of IPN have arguably been minimally invasive (peri-) pancreatic necrosectomy
(MIPN) and the trend toward delayed intervention. The drive toward the use of less invasive techniques has been fueled by
the high morbidity and mortality rates (up to 25%) (Besselink et al. 2006a) associated with necrosectomy by laparotomy (Windsor
2007). The timing of surgical intervention has been addressed frequently in recent years. Early proponents of delayed intervention
reasoned that operative intervention should be avoided during the initial 1-2 weeks, the “systemic inflammatory response syndrome
(SIRS)-phase,” but recently, it has been suggested that intervention in IPN should be delayed even further to allow for encapsulation
of the infected necrosis. This latter approach greatly facilitates the use of minimally invasive techniques (Forsmark and
Baillie 2007). In order to design adequate future prospective studies we performed a systematic literature review and critical
appraisal of the available evidence on the use of MIPN and delayed intervention in IPN.
12/2009: pages 21-30;
-
Journal of clinical epidemiology 12/2009; 63(4):353-4. · 2.96 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The management of infected peripancreatic or pancreatic necrosis in patients with severe pancreatitis has changed considerably in recent years. This review discusses the recent literature on prevention, detection, and management of infected necrosis. Though antibiotics, probiotics, and enteral nutrition have been tried to prevent infected necrosis, only enteral nutrition has consistently proven to be effective. Antibiotics and probiotics have not shown a consistent beneficial effect on outcome. Enteral nutrition reduced infectious complications and mortality in severe pancreatitis, compared with parenteral nutrition. The detection of infection of pancreatic necrosis is important for clinical decision making. Fine-needle aspiration may be used to confirm suspected infection, but if its results will not change clinical decisions, it should be omitted, as it may even introduce infection. Minimally invasive surgical, radiologic, or endoscopic intervention is increasingly being applied. In the absence of level 1 evidence, local expertise dictates which type of intervention is applied.
Current Gastroenterology Reports 05/2009; 11(2):104-10.
-
Nature Clinical Practice Gastroenterology & Hepatology 04/2009; 6(3):E3-6. · 5.33 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To compare the effect of enteral vs parenteral nutrition in patients with severe acute pancreatitis for clinically relevant outcomes.
A computerized literature search was performed in the MEDLINE, EMBASE, and Cochrane databases for articles published from January 1, 1966, until December 15, 2006.
From 253 publications screened, 5 randomized controlled trials comparing enteral and parenteral nutrition in patients with predicted severe acute pancreatitis met the inclusion criteria.
Information on study design, patient characteristics, and acute pancreatitis outcomes were independently extracted by two of us using a standardized protocol.
A meta-analysis of randomized controlled trials was performed using a random-effects model. Enteral feeding reduced the risk of infectious complications (relative risk, 0.47; 95% confidence interval, 0.28-0.77; P < .001), pancreatic infections (0.48; 0.26-0.91; P = .02), and mortality (0.32; 0.11-0.98; P = .03). The risk reduction for organ failure was not statistically significant (0.67; 0.30-1.52; P = .34).
Enteral nutrition results in clinically relevant and statistically significant risk reduction for infectious complications, pancreatic infections, and mortality in patients with predicted severe acute pancreatitis.
Archives of surgery (Chicago, Ill.: 1960) 11/2008; 143(11):1111-7. · 4.32 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Early endoscopic retrograde cholangiopancreatography (ERCP) should be performed in all patients with acute biliary pancreatitis (ABP) and coexisting acute cholangitis. In patients without cholangitis and predicted mild ABP it is generally accepted that early ERCP should not be performed. Nevertheless, there is a controversy regarding the role of early ERCP in the treatment of patients with predicted severe ABP without cholangitis. We reviewed randomized trials on early ERCP versus conservative management in patients with ABP without acute cholangitis.
Relevant publications in 3 electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) were systematically reviewed and meta-analyzed.
Seven randomized trials on ERCP in acute pancreatitis were found, of which 3 including a total of 450 patients (230 in the invasive arm and 220 in the control arm) qualified for a meta-analysis according to predefined criteria. In all patients with ABP (predicted mild and severe), early ERCP was associated with a nonsignificant reduction in overall complications [risk ratio (RR) 0.76; 95% confidence interval (CI) 0.41-1.04; P = 0.38] and a nonsignificant increase in mortality (RR 1.13; 95% CI 0.23-5.63; P = 0.88). Subgroup analysis based on predicted severity did not affect these outcomes (overall complications: predicted mild: RR 0.86; 95% CI 0.62-1.19; P = 0.36; predicted severe: RR 0.82; 95% CI 0.32-2.10; P = 0.68; mortality: predicted mild: RR 1.90; 95% CI 0.25-14.55; P = 0.53; predicted severe: RR 1.28; 95% CI 0.20-8.06; P = 0.80).
In this meta-analysis, early ERCP in patients with predicted mild and predicted severe ABP without acute cholangitis did not lead to a significant reduction in the risk of overall complications and mortality.
Annals of Surgery 03/2008; 247(2):250-7. · 7.49 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Infected pancreatic and peripancreatic necrosis in acute pancreatitis is potentially lethal, with mortality rates up to 35%. Therefore, there is growing interest in minimally invasive treatment options, such as (EUS-guided) endoscopic transgastric necrosectomy.
Retrospective cohort study on EUS-guided endoscopic transgastric necrosectomy in patients with infected necrosis in acute pancreatitis.
8 patients (age 38-75, mean 50 years) with documented infected peripancreatic or pancreatic necrosis were included. Median time to first intervention was 33 days (range 17-62) after onset of symptoms. At the time of first intervention 2 patients had organ failure. All patients were managed on the patient ward. Initial endoscopic drainage was successful in all patients, a median of 4 (range 2-6) subsequent endoscopic necrosectomies were needed to remove all necrotic tissue. Two patients needed additional surgical intervention because of pneumoperitoneum (n = 1) and insufficient endoscopic drainage (n = 1). Six patients recovered, with 1 mild relapse during follow-up (median 12, range 8-60 months). One patient died.
EUS-guided endoscopic transgastric necrosectomy of infected necrosis in acute pancreatitis appears to be a feasible and relatively safe treatment option in patients who are not critically ill. Further randomized comparison with the current 'gold standard' is warranted to determine the place of this treatment modality.
Pancreatology 02/2008; 8(3):271-6. · 1.99 Impact Factor
-
Marc G H Besselink,
Hjalmar C van Santvoort,
Erik Buskens,
Marja A Boermeester,
Harry van Goor,
Harro M Timmerman,
Vincent B Nieuwenhuijs,
Thomas L Bollen,
Bert van Ramshorst,
Ben J M Witteman, [......],
Menno A Brink,
Alexander F M Schaapherder,
Cornelis H C Dejong,
Peter J Wahab,
Cees J H M van Laarhoven,
Erwin van der Harst,
Casper H J van Eijck,
Miguel A Cuesta,
Louis M A Akkermans,
Hein G Gooszen
[show abstract]
[hide abstract]
ABSTRACT: Infectious complications and associated mortality are a major concern in acute pancreatitis. Enteral administration of probiotics could prevent infectious complications, but convincing evidence is scarce. Our aim was to assess the effects of probiotic prophylaxis in patients with predicted severe acute pancreatitis.
In this multicentre randomised, double-blind, placebo-controlled trial, 298 patients with predicted severe acute pancreatitis (Acute Physiology and Chronic Health Evaluation [APACHE II] score > or =8, Imrie score > or =3, or C-reactive protein >150 mg/L) were randomly assigned within 72 h of onset of symptoms to receive a multispecies probiotic preparation (n=153) or placebo (n=145), administered enterally twice daily for 28 days. The primary endpoint was the composite of infectious complications--ie, infected pancreatic necrosis, bacteraemia, pneumonia, urosepsis, or infected ascites--during admission and 90-day follow-up. Analyses were by intention to treat. This study is registered, number ISRCTN38327949.
One person in each group was excluded from analyses because of incorrect diagnoses of pancreatitis; thus, 152 individuals in the probiotics group and 144 in the placebo group were analysed. Groups were much the same at baseline in terms of patients' characteristics and disease severity. Infectious complications occurred in 46 (30%) patients in the probiotics group and 41 (28%) of those in the placebo group (relative risk 1.06, 95% CI 0.75-1.51). 24 (16%) patients in the probiotics group died, compared with nine (6%) in the placebo group (relative risk 2.53, 95% CI 1.22-5.25). Nine patients in the probiotics group developed bowel ischaemia (eight with fatal outcome), compared with none in the placebo group (p=0.004).
In patients with predicted severe acute pancreatitis, probiotic prophylaxis with this combination of probiotic strains did not reduce the risk of infectious complications and was associated with an increased risk of mortality. Probiotic prophylaxis should therefore not be administered in this category of patients.
The Lancet 02/2008; 371(9613):651-9. · 38.28 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine the effect of timing of surgical intervention for necrotizing pancreatitis.
Retrospective study of 53 patients and a systematic review.
A tertiary referral center. Main Outcome Measure Mortality.
Median timing of the intervention was 28 days. Eighty-three percent of patients had infected necrosis and 55% had preoperative organ failure. The mortality rate was 36%. Sixteen patients were operated on within 14 days of initial admission, 11 patients from day 15 to 29, and 26 patients on day 30 or later. This latter group received preoperative antibiotics for a longer period (P < .001), and Candida species and antibiotic-resistant organisms were more often cultured from the pancreatic or peripancreatic necrosis in these patients (P = .02). The 30-day group also had the lowest mortality (8% vs 75% in the 1 to 14-days group and 45% in the 15 to 29-days group, P < .001); this difference persisted when outcome was stratified for preoperative organ failure. During the second half of the study, necrosectomy was further postponed (43 vs 20 days, P = .06) and mortality decreased (22% vs 47%, P = .09). We also reviewed 11 studies with a total of 1136 patients. Median surgical patient volume was 8.3 patients per year (range, 5.3-15.6), median timing of surgical intervention was 26 days (range, 3-31), and median mortality was 25% (range, 6%-56%). We observed a significant correlation between timing of intervention and mortality (R = - 0.603; 95% confidence interval, - 2.10 to - 0.02; P = .05).
Postponing necrosectomy until 30 days after initial hospital admission is associated with decreased mortality, prolonged use of antibiotics, and increased incidence of Candida species and antibiotic-resistant organisms.
Archives of surgery (Chicago, Ill.: 1960) 12/2007; 142(12):1194-201. · 4.32 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Imaging of patients with acute pancreatitis requires an understanding of the subtypes and complications that were defined at the Atlanta symposium in 1992. In the last decade, several new entities have been recognized with important clinical implications. In this article, the radiological aspects of the terminology and classification of acute pancreatitis are reviewed and new entities are clarified. The roles of ultrasound, computed tomography, and magnetic resonance imaging in the diagnosis and evaluation of acute pancreatitis and its complications are discussed and the limitations of each imaging technique, when interpreting pancreatic and peripancreatic inflammatory disease, are addressed.
Seminars in Ultrasound CT and MRI 11/2007; 28(5):371-83. · 1.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Oral refeeding in patients recovering from acute pancreatitis may cause pain relapse. Patients with pain relapse may be ill for prolonged periods, thereby consuming additional health care resources. We aimed to determine the incidence and risk factors of pain relapse on the basis of reviewing all studies on oral refeeding in acute pancreatitis.
Relevant literature cited in three electronic databases (Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE) as well as the abstracts of major gastroenterological meetings was reviewed. Outcome measures studied were the incidence of pain relapse and length of hospital stay.
A total of three studies met the inclusion criteria. Sixty of 274 patients (21.9%) experienced pain relapse during the course of acute pancreatitis. In 47 of 60 (78.3%) patients pain relapse occurred within 48 h after commencement of oral refeeding. Two studies showed a significantly higher Balthazar's CT score on hospital admission in patients with pain relapse, whereas all three studies found no difference in the severity scores between patients with and without pain relapse. All three studies found a significant increase in the length of hospital stay in patients with pain relapse.
The incidence of pain relapse after oral refeeding in acute pancreatitis is relatively high. Thereby, the quest for new therapeutical modalities that can prevent pain relapse is of current importance.
The American Journal of Gastroenterology 10/2007; 102(9):2079-84; quiz 2085. · 7.28 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The 1992 Atlanta classification is a clinically based classification system that defines the severity and complications of acute pancreatitis. The purpose of this review was to assess whether the terms abandoned by the Atlanta classification are really discarded in the literature. The second objective was to review what new terms have appeared in the literature since the Atlanta symposium.
We followed a Medline search strategy in review and guideline articles after the publication of the Atlanta classification. This search included the abandoned terms: "phlegmon," "infected pseudocyst," "hemorrhagic pancreatitis," and "persistent pancreatitis."
A total of 239 publications were reviewed, including 10 guideline articles and 42 reviews. The abandoned terms "hemorrhagic pancreatitis" and "persistent pancreatitis" are hardly encountered, in contrast, both "infected pseudocyst" and "phlegmon" are frequently used, and several authors question their abandonment. New terminology in acute pancreatitis consists of "organized pancreatic necrosis," "necroma," "extrapancreatic necrosis," and "central gland necrosis."
This review demonstrates that the Atlanta classification is still not universally accepted. Several abandoned terms are frequently used, and new terms have emerged that describe manifestations in acute pancreatitis that were not specifically addressed during the Atlanta symposium.
Pancreas 09/2007; 35(2):107-13. · 2.39 Impact Factor
-
Pancreas 06/2007; 34(4):477-9. · 2.39 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This study provides an update on the treatment of severe acute pancreatitis (SAP) with emphasis on nutrition, infection-prophylaxis, biliary pancreatitis, surgical intervention and new randomized controlled trials.
The most relevant new insights are: (i) early enteral nutrition in SAP is not only capable of reducing infectious complications but may also reduce mortality; (ii) there is increasing evidence that antibiotic-prophylaxis is not capable of preventing infectious complications in SAP; (iii) probiotic-prophylaxis is being considered as an alternative with promising experimental results; (iv) in biliary pancreatitis, early endoscopic retrograde cholangiography with sphincterotomy (within 48 h) is beneficial in case of ampullary obstruction, although it may be withheld in the event of negative endoscopic ultrasound; (v) surgical intervention for infected (peri-)pancreatic necrosis is increasingly being postponed; (vi) minimally invasive strategies are being considered as a full alternative for necrosectomy by laparotomy in infected (peri-)pancreatic necrosis; (vii) the Atlanta classification should no longer be used to describe computed tomography findings in acute pancreatitis; and (viii) only five randomized controlled trials of patients with acute pancreatitis are currently registered in the international trial registries.
Timing of intervention is becoming increasingly important in SAP management.
Current Opinion in Critical Care 05/2007; 13(2):200-6. · 2.51 Impact Factor
