Imaging classification and analysis of the diagnosis and treatment of infected pancreatic necrosis:a report of 126 cases / 中华外科杂志

Objective: To explore the clinical characteristics of various types of infected pancreatic necrosis(IPN) and the prognosis of different treatment methods in the imaging classification of IPN proposed. Methods: The clinical data of 126 patients with IPN admitted to the Department of Pancreatic and Biliary Surgery, the First Affiliated Hospital of Harbin Medical University from December 2018 to December 2021 were analyzed retrospectively. There were 70 males(55.6%) and 56 females(44.4%), with age(M(IQR)) of 44(17)years (range: 12 to 87 years). There were 67 cases(53.2%) of severe acute pancreatitis and 59 cases (46.8%) of moderately severe acute pancreatitis. All cases were based on the diagnostic criteria of IPN. All cases were divided into Type Ⅰ(central IPN)(n=21), Type Ⅱ(peripheral IPN)(n=23), Type Ⅲ(mixed IPN)(n=74) and Type Ⅳ(isolated IPN)(n=8) according to the different sites of infection and necrosis on CT.According to different treatment strategies,they were divided into Step-up group(n=109) and Step-jump group(n=17). The clinical indicators and prognosis of each group were observed and analyzed by ANOVA,t-test,χ2 test or Fisher exact test,respectively. Results: There was no significant difference in mortality, complication rate and complication grade in each type of IPN(all P>0.05). Compared with other types of patients, the length of stay (69(40)days vs. 19(19)days) and hospitalization expenses(323 000(419 000)yuan vs. 60 000(78 000)yuan) were significantly increased in Type Ⅳ IPN(Z=-4.041, -3.972; both P<0.01). The incidence of postoperative residual infection of Type Ⅳ IPN was significantly higher than that of other types (χ2=16.350,P<0.01). There was no significant difference in the mortality of patients with different types of IPN between different treatment groups. The length of stay and hospitalization expenses of patients in the Step-up group were significantly less than those in the Step-jump group(19(20)days vs. 33(35)days, Z=-2.052, P=0.040;59 000(80 000)yuan vs. 122 000(109 000)yuan,Z=-2.317,P=0.020). Among the patients in Type Ⅳ IPN, the hospitalization expenses of Step-up group was significantly higher than that of Step-jump group(330 000(578 000)yuan vs. 141 000 yuan,Z=-2.000,P=0.046). The incidence of postoperative residual infection of Step-up group(17.4%(19/109)) was significantly lower than that of Step-jump group(10/17)(χ2=11.980, P=0.001). Conclusions: Type Ⅳ IPN is more serious than the other three types. It causes longer length of stay and more hospitalization expenses. The step-up approach is safe and effective in the treatment of IPN. However, for infected lesions which are deep in place,difficult to reach by conventional drainage methods, or mainly exhibit "dry necrosis", choosing the step-jump approach is a more positive choice.

Basic principles,methods and evaluation of minimally invasive treatment for infected pancreatic necrosis / 中华外科杂志

Infected pancreatic necrosis(IPN) is the main surgical indication of acute pancreatitis. Minimally invasive debridement has become the mainstream surgical strategy of IPN,and it is only preserved for IPN patients who are not response for adequate non-surgical treatment. Transluminal or retroperitoneal drainage is preferred,and appropriate debridement can be performed. At present,it is reported that video assisted transluminal,trans-abdominal and retroperitoneal approaches can effectively control IPN infection. However,in terms of reducing pancreatic leakage and other complications,surgical and endoscopic transgastric debridement may be the future direction in the treatment of IPN.

Manejo quirúrgico de pseudoquiste pancreático gigante: caso clínico / Surgical management of giant pancreatic pseudocyst: case report

Resumen Introducción: Los pseudoquistes pancreáticos (PQP) corresponden al 80% de las lesiones quísticas del páncreas. Se debe descartar un tumor quístico, que representan el 10% al 15% de los quistes del páncreas y 1% de los tumores malignos por lo que es fundamental el estudio y diagnóstico diferencial. El término pseudoquiste pancreático gigante se usa tradicionalmente cuando el tamaño es mayor de 10 cm. Hay pocos casos de PQP gigantes en la literatura nacional. Objetivo: Reportar caso clínico con PQP gigante, analizar el diagnóstico diferencial y las opciones terapéuticas. Materiales y Método: Paciente con distensión abdominal progresiva, pérdida de peso y anorexia, posepisodio de pancreatitis aguda. Tomografía computarizada abdominal y resonancia magnética confirman lesión quística gigante intraabdominal. El paciente fue tratado con una cistoyeyunostomía pancreática abierta en Y de Roux. El análisis del contenido aspirado durante la cirugía sugiere PQP. Para la discusión se revisa la literatura más relevante. Resultados: Excelente resultado clínico postoperatorio, el estudio histopatológico de la pared del quiste confirmó el diagnóstico de pseudoquiste pancreático. Al año de seguimiento, el paciente permanece asintomático. Discusión: El estudio preoperatorio es crucial para determinar el diagnóstico diferencial y descartar lesiones neoplásicas o parasitarias quísticas. Los PSQ gigantes reportados son poco frecuentes y su manejo quirúrgico dependerá fundamentalmente de su tamaño, de las relaciones anatómicas y de la experiencia del equipo tratante.

Introduction: Pancreatic pseudocysts (PQP) correspond to 80% of cystic lesions of the pancreas. A cystic tumor must be ruled out, which represents 10% to 15% of pancreatic cysts and 1% of malignant tumors, so the study and differential diagnosis is essential. The term giant pancreatic pseudocyst is traditionally used when the size is greater than 10 cm. There are few cases of giant PQP in the national literature. Objective: To report a clinical case with giant PQP, to analyze the differential diagnosis and therapeutic options. Materials and Method: Patient with progressive abdominal distension, weight loss and anorexia post episode of acute pancreatitis. Abdominal computed tomography and magnetic resonance imaging confirm a giant intra-abdominal cystic lesion. The patient was treated with an open Roux-en-Y pancreatic cysto-jejunostomy. Analysis of the content aspirated during surgery suggests PQP. The most relevant literature is reviewed for discussion. Results: Excellent postoperative clinical results, the histopathological study of the cyst wall, confirmed the diagnosis of pancreatic pseudocyst. At one year of follow-up, the patient remains asymptomatic. Discussion: The preoperative study is crucial to determine the differential diagnosis and rule out neoplastic or cystic parasitic lesions. Reported giant PSQs are rare and their surgical management will depend fundamentally on their size, anatomical relationships, and the experience of the treating team.

Familial chylomicronemia syndrome-induced acute necrotizing pancreatitis during pregnancy

Abstract Acute pancreatitis is a rare condition in pregnancy, associated with a high mortality rate. Hypertriglyceridemia represents its second most common cause.We present the case of a 38-year-old woman in the 24th week of gestation with a history of hypertriglyceridemia and recurrent episodes of pancreatitis. She was admitted to our hospital with acute pancreatitis due to severe hypertriglyceridemia. She was stabilized and treated with fibrates. Despite her favorable clinical course, she developed a second episode of acute pancreatitis complicated by multi-organ dysfunction and pancreatic necrosis, requiring a necrosectomy. The pregnancy was ended by cesarean section, after which three plasmapheresis sessions were performed. She is currently asymptomatic with stable triglyceride levels. Acute pancreatitis due to hypertriglyceridemia represents a diagnostic and therapeutic challenge in pregnant women, associated with serious maternal and fetal complications. When primary hypertriglyceridemia is suspected, such as familial chylomicronemia syndrome, the most important objective is preventing the onset of pancreatitis.

Glycogen synthase kinase-3 beta inhibitors protectagainst the acute lung injuries resulting from acute necrotizing pancreatitis

Abstract Purpose The research is intended for clarification of the efficacy as well as the underlying mechanism of GSK-3β inhibitors on the advancement of acute lung injuries in acute necrotizing pancreatitis (ANP) in rats. Methods Seventy-two rats were randomly divided into 6 groups: (1)ANP-vehicle; (2)ANP-TDZD-8;(3)ANP-SB216763;(4)Sham-vehicle;(5)Sham-TDZD-8;(6)Sham-SB216763; Blood biochemical test, histopathological examination and immunohistochemical analysis of rats pancreas and lung tissues were performed. The protein expression of GSK-3β, phospho-GSK-3β (Ser9), iNOS, ICAM-1, TNF-α, and IL-10 were detected in lung tissues by Western-blot. Results The outcomes revealed that the intervention of GSK-3β inhibitors alleviated the pathological damage of pancreas and lung (P<0.01), reduced serum amylase, lipase, hydrothorax and lung Wet-to-Dry Ratio, attenuated serum concentrations of IL-1β and IL-6 (P<0.01), inhibited the activation of NF-κB, and abated expression of iNOS, ICAM-1 and TNF-α protein, but up-regulated IL-10 expression in lung of ANP rats (P<0.01). The inflammatory response and various indicators in ANP-TDZD-8 groups were lower than those in ANP-SB216763 groups. Conclusions Inhibition of GSK-3β weakens acute lung injury related to ANP via the inhibitory function of NF-κB signaling pathway. Different kinds of GSK-3β inhibitors have different effects to ANP acute lung injury.

Agenesia de la Vesícula Biliar asociada a pancreatitis aguda recurrente. Presentación de caso / Gall bladder agenesis associated with recurrent acute pancreatitis. Case presentation

Introducción: La Agenesia de la Vesícula Biliar es una anomalía congénita rara, entre 13 y 65 por ciento por cada 100 000 habitantes. Su asociación con pancreatitis aguda es extremadamente rara. Objetivo: Presentar un caso de Agenesia de la Vesícula Biliar asociada a pancreatitis aguda recurrente. Presentación del caso: Se presenta una mujer de 85 años, con antecedentes de litiasis vesicular por ultrasonido (US), y crisis de dolor abdominal, vómitos e hipotensión frecuentes, a quien remitían con tratamiento médico. Acudió al hospital con dolor abdominal, vómitos e hipotensión. Al examen físico se constató: dolor epigástrico, sin reacción peritoneal ni tumor palpable. El US informó vesícula no visible. En menos de 24 horas evolucionó con shock, disfunción múltiple de órganos y muerte. En la necropsia se encontró Agenesia de la Vesícula Biliar (AVB) y pancreatitis aguda necrotizante. Conclusiones: La AVB es una anomalía congénita rara, de difícil diagnóstico preoperatorio, por lo que casi siempre es un hallazgo de la cirugía abdominal o en la autopsia. Su asociación con pancreatitis aguda es rara. La pancreatitis puede ser debida a Disfunción del Esfínter de Oddi o de origen idiopático(AU)

Introduction: Gallbladder agenesis (GA) is a rare congenital anomaly, with a reported incidence ranging between 13-65 percent a 100 000 population. Its association with acute pancreatitis is extremely rare. Objective: To present a case of GA associated with recurrent acute pancreatitis. Case Presentation: We present an 85 years old woman whose clinical record reported a bladder stonediagnosis by US, that arrive to the hospital with frequent episodes of intermittent vomiting, abdominal pain and hypotension. She was admitted at hospital with upper abdominal pain, vomiting and hypotension. At the physical examination the abdomen was soft, with mild epigastric tenderness, without tenderness rebound or tumor. US report gallbladder not visible. In less than 24 hours the patient evolved with shock, multiple organ failure and death. Gallbladder agenesis and acute pancreatitis were found in autopsy. Conclusions: The GA is a rare congenital anomaly, difficult to establish a correct preoperative diagnosis, always found during the abdominal surgery or autopsy. Its association with acute pancreatitis is very uncommon. Pancreatitis may be due to of Oddi Sphincter's Dysfunction (SOD) or idiopathic origin(AU)

Therapeutic alternatives for the treatment of infected pancreatic necrosis: an overview / Alternativas terapéuticas para el tratamiento de la necrosis pancreática infecciosa: una visión general

Despite diagnostic and therapeutic advances, the treatment of infected pancreatic necrosis (IPN) continues to be a complex problem to solve. The aim of this study is to evaluate the effectiveness of different surgical alternatives for the treatment of IPN. Articles published between 2000 to 2013, and related to effectiveness of open surgery (OS) and minimally invasive treatmente (MIT) in patients with IPN were evaluated. PubMed, MEDLINE, The Cochrane Database of Systematic Reviews, Cochrane Central Register RCT, DARE, IBECS, SciELO, LILACS, PAHO, WHOLIS, ASERNIP-S, NIHR, HTA, Clinical Excellence, York Health Economic Consortium and Tripdatabase were reviewed, searching systematic reviews (SR), randomized clinical trials (RCT) and observational studies (OST), in which the effectiveness of OS and MIT was evaluated in relation to the variables mortality, intra-abdominal bleeding, development of enterocutaneous fistula or hollow viscera perforation, development of pancreatic fistula, reoperations for complications, reoperations for new necrosectomy, development of diabetes mellitus and pancreatic enzyme requirements. Three hundred eighty-nine articles were retrieved, 10 of which met the selection criteria (2 SR, 1 RCT and 7 OST). The studies have a level of evidence of 2a, 2b, 3a and 4. MIT are associated with better results than OS in all variables analyzed, but significantly only in the development of diabetes mellitus and pancreatic enzyme requirement. Articles found are few and heterogeneous, making meaningful conclusions difficult. Studies with a better level of evidence, methodological quality and population size are needed to make conclusions and recommendations.

A pesar de los avances diagnósticos y terapéuticos, el tratamiento de la necrosis pancreática infecciosa (NPI) sigue siendo un problema complejo de resolver. El objetivo de este estudio es evaluar la eficacia de las diferentes alternativas quirúrgicas para el tratamiento del NPI. Fueron evaluados artículos publicados entre 2000 y 2013, relacionados con la efectividad de la cirugía abierta (CA) y el tratamiento mínimamente invasivo (TMI) en pacientes diagnosticados con NPI. Se PubMed, MEDLINE, The Cochrane Database of Systematic Reviews, Cochrane Central Register RCT, DARE, IBECS, SciELO, LILACS, PAHO, WHOLIS, ASERNIP-S, NIHR, HTA, Clinical Excellence, York Health Economic Consortium y Tripdatabase, en búsqueda de revisiones sistemáticas (RS), ensayos clínicos aleatorios (ECA) y estudios observacionales (EO). En estos estudios se evaluó la eficacia de la cirugía y el TMI en relación con diferentes variables, como la mortalidad, el sangrado intra-abdominal, el desarrollo de fístula enterocutánea o la perforación de víscera hueca, el desarrollo de fístula pancreática, reintervenciones por complicaciones, reintervenciones por necrosectomía, el desarrollo de diabetes mellitus y la necesidad de enzimas pancreáticas. Se consiguieron 389 artículos, de los cuales 10 cumplieron con los criterios de selección (2 RS, 1 ECA y 7 EO). Los estudios presentaron un nivel de evidencia de 2a, 2b, 3a y 4. El TMI se asocia con mejores resultados que la CA en todas las variables analizadas, pero en forma significativa sólo en el desarrollo de la diabetes mellitus y la necesidad de enzimas pancreáticas. Los artículos encontrados son pocos y heterogéneos, lo que hace difícil poder alcanzar conclusiones significativas. Se necesitan estudios con un mejor nivel de evidencia, calidad metodológica y tamaño de población estudiada para poder establecer conclusiones y recomendaciones.

Balloon Occlusion Retrograde Transvenous Obliteration of Gastric Varices in Two Non-Cirrhotic Patients with Portal Vein Thrombosis

This report describes two non-cirrhotic patients with portal vein thrombosis who underwent successful balloon occlusion retrograde transvenous obliteration (BRTO) of gastric varices with a satisfactory response and no complications. One patient was a 35-year-old female with a history of Crohn's disease, status post-total abdominal colectomy, and portal vein and mesenteric vein thrombosis. The other patient was a 51-year-old female with necrotizing pancreatitis, portal vein thrombosis, and gastric varices. The BRTO procedure was a useful treatment for gastric varices in non-cirrhotic patients with portal vein thrombosis in the presence of a gastrorenal shunt.

Inibição da guanilato ciclase pelo azul de metileno no choque circulatório causado por pancreatite aguda necrosante: uma palavra de cuidado embasada em modelo suíno / Guanylate cyclase inhibition by methylene blue in circulatory shock caused by acute necrotizing pancreatitis: a word of caution based on a porcine model

OBJETIVO: estudar o uso terapêutico do bloqueio da guanilato ciclase pelo azul de metileno em um modelo experimental de pancreatite aguda grave em suínos. MÉTODOS: a pancreatite aguda necrotizante foi induzida em porcos anestesiados por infusão ductal pancreática retrógrada de 1ml/kg de taurocolato de sódio a 5% e 8U/kg de enteroquinase. Três grupos foram estudados (n=5): controle (C), pancreatite (PA), "bolus" de azul seguido por pancreatite (AM+PA). Os dados incluíram enzimas séricas e do líquido abdominal, variáveis hemodinâmicas, hemogasometria arterial, volume de líquido abdominal, marcadores inflamatórios plasmáticos, nitrito/nitrato e mieloperoxidase e malondialdeído plasmático. Aplicou-se a análise de variância seguida do pós-teste de Bonferroni (p<0,05). RESULTADOS: os valores de amilase e lipase foram três e dez vezes mais elevados no grupo PA. A atividade da mieloperoxidase foi 50% superior no grupo PA. Os dados hemodinâmicos indicaram choque hipovolêmico precoce seguido de choque cardiogênico. Observou-se grave translocação de líquidos para a cavidade peritoneal. A nitrito/nitrato plasmática permaneceu inalterada. O grupo AM+PA teve aumento de cinco vezes do mieloperoxidase em comparação com o grupo C. CONCLUSÕES: a utilização de azul de metileno em suínos com pancreatite não demonstrou efeitos significativos sobre variáveis hemodinâmicas e inflamatórias. Seu uso terapêutico na pancreatite necro-hemorrágica pode ser inadequado e extremo cuidado deve ser tomado dado o aumento da peroxidação lipídica evidenciado pelo aumento dos valores do malondialdeído.

OBJECTIVE: To study the therapeutic application of guanylate cyclase inhibition by methylene blue in an experimental model of acute pancreatitis in pigs. METHODS: acute necrotizing pancreatitis was induced in anesthetized pigs by the retrograde infusion of 1 ml/kg of 5% sodium taurocholate and 8 U/kg enterokinase in the pancreatic duct. Three groups were studied (n = 5): control (C), pancreatitis (AP), and MB bolus followed by pancreatitis (MB+P). The data included serum and abdominal fluid enzymes, hemodynamic variables, arterial hemogasometry, abdominal fluid volume, inflammatory markers, plasma nitrite/nitrate (NOx), plasma myeloperoxidase (MPO) and plasma malondialdehyde (MDA). One- and two-way analysis of variance (ANOVA) was performed, followed by the Bonferroni test (p < 0.05). RESULTS: amylase and lipase were three and 10-fold higher in the AP group. Myeloperoxidase activity was 50% higher in the AP group. The hemodynamic data indicated early hypovolemic shock followed by cardiogenic shock. Severe fluid translocation to the peritoneal cavity was observed. Plasma NOx remained unchanged. The MB+P group had a five-fold increase in MDA compared with the C group. CONCLUSION: preemptive application of MB in pigs with AP demonstrated no significant effects on hemodynamic and inflammatory variables. The use of MB is inadequate in cases of exponential NO release, and extreme caution must be exercised, given the increase in lipid peroxidation based on the malondialdehyde dosage.

Pancreatite aguda: terapêutica clínica / Acute pancreatitis: clinical therapeutic

Um dos grandes desafios da medicina clínica cirúrgica é a terapêutica da pancreatite aguda (PA), em especial na forma grave, na qual a necrose da glândula e da gordura peripancreática tem sido o fator de risco predominante para a má evolução. Nos EUA, mais de 300 mil pacientes são admitidos anualmente por conta da PA e cerca de 20 mil evoluem para óbito neste mesmo período. A prevenção da síndrome de resposta inflamatória sistêmica (SRIS), da infecção e da sepse diminuiria a falência múltipla de órgãos e a morbiletalidade

One of the challenges in clinical medicine surgery is the treatment of acute pancreatitis (PA), specially in severe ones, in which gland necrosis and fat peripancreatic have been the main risk fact for not effective evolution. In USA, over three hundred thousand of patients are anually admitted due acute pancreatitis and about two hundred thousand of patients die in this same phase. The prevention for systemic inflammatory response syndrome, infection and sepsis would reduce multiple organ failure and the mortality

Evaluación y validación de las indicaciones quirúrgicas en la pancreatitis aguda con necrosis, en el Hospital Nacional Edgardo Rebagliati Martins / Evaluation and validation of surgical indications in acute pancreatitis with necrosis, at the National Hospital Edgardo Rebagliati Martins

OBJETIVO: El objetivo de este estudio es evaluar la eficacia de las indicaciones quirúrgicas en la pancreatitis aguda. MATERIALES Y MÉTODOS: Durante el periodo comprendido entre Mayo del 2000 a Junio del 2009 se realizo un estudio de manera prospectiva donde se incluyo a 107 pacientes con Pancreatitis aguda grave con necrosis que fueron operados en la Unidad de Pancreatitis del Hospital Rebagliati. Se dividió a los pacientes de acuerdo a la indicación quirúrgica recibida. Indicación A: Aquellos pacientes que fueron operados por presentar punción por aguja fina positiva (PAF) Indicación B: Pacientes operados por presentar sepsis en ausencia de foco infeccioso extra pancreático. RESULTADOS: Cuando evaluamos la efectividad de cada indicación quirúrgica para detectar infección de la necrosis pancreática pudimos observar que cuando se opero al paciente utilizando la indicación quirúrgica A el 89% presentaban necrosis pancreática infectada, mientras que cuando se utilizo la indicación B solo se encontró infección de la necrosis pancreática en el 51% de los casos (p=0.001). Por lo tanto cuando se utilizo la primera indicación solo el 11% de los operados presento una necrosis estéril mientras que cuando usamos la indicación B operamos por ôerrorõ de esta a un 48% de pacientes que no tenían una indicación quirúrgica por no presentar una necrosis infectada. CONCLUSIONES: La punción por aguja fina es la indicación quirúrgica por excelencia en la pancreatitis aguda grave con necrosis descartando a la indicación de ôSepsisõ en ausencia de foco infeccioso extra pancreático que no responde al tratamiento en UCI por más de 72 horas (indicación B), ya que no es una adecuada indicación porque nos induce a operar pacientes que no tienen una real indicación quirúrgica (necrosis estéril) debido a que estos pacientes pueden ser manejados médicamente.

OBJECTIVE: The purpose of this study is to evaluate efficacy of the surgical indications in acute pancreatitis MATERIAL AND METHODS: During the period from May 2000 to June 2009, 107 operated patients with pancreatic necrosis were treated in the Severe Acute Pancreatitis Unit of the HNERM a comparison was made by separating the patients in two groups according to the surgical indication. An analysis was carried out in order to evaluate which type of surgical indication has the best results according to age, severity of the case, return to oral intake, hospital stay, complications and mortality. RESULTS: On evaluating the indication by positive puncture for detecting necrosis infection we found that 89% of the patients operated due to this indication showed infected necrosis while those operated due to the indication of sepsis without response to the ICU treatment only reached 51%. Surgical complications and re operations, was higher among the patients whose indication was sepsis without response to the ICU treatment (Indication B) in comparison with positive FNA. (Indication A) CONCLUSION: Positive fine needle aspiration is the surgical indication par excellence in acute pancreatitis with necrosis. We consider that the indication of sepsis that do not respond for more than 72 hours to treatment in the ICU regardless that negative FNA should not be taken into account, due to the very high percentage of sterile necrosis found at the time of surgery.

Identificando a la Pancreatitis aguda severa / Identifying the severe acute pancreatitis

OBJETIVOS: Comparar a pacientes con pancreatitis aguda con necrosis que no presentan complicaciones adicionales durante su hospitalización (Grupo A) versus aquellos pacientes con pancreatitis aguda con necrosis que presenten complicaciones adicionales durante su hospitalización (Grupo B). MÉTODOS: Se realizó el análisis sobre una base de datos preexistente de registros de pacientes hospitalizados con diagnóstico de pancreatitis aguda con necrosis de la Unidad de Pancreatitis Aguda Grave del Hospital Nacional Edgardo Rebagliati Martins entre 2000 y 2010. Se utilizaron los registros de todos los pacientes criterios diagnósticos de pancreatitis aguda severa con presencia de necrosis mayores de 18 años. RESULTADOS: Se incluyeron 215 registros de pacientes con PA con necrosis. Los pacientes del Grupo A representaron un 32% (68) y los del Grupo B el 68%(147). Grupo A tuvo un promedio de 39 días de hospitalización y el Grupo B tuvo un promedio de 56 días (p = 0.01). Del Grupo A 22% tuvieron más de 50% de necrosis mientras 43% del Grupo B tuvieron esta extensión de necrosis (p <0.05, OR 3.4, IC (1.12-10)). De los 14 casos fallecidos de toda la población, encontrándose todos ellos en el Grupo B, 12 de ellos tuvieron más de 50% de necrosis. CONCLUSIONES: No todos los casos clasificados como pancreatitis aguda severa, basados en la presencia de necrosis pancreática, se comportan de manera uniforme. Es la extensión de la necrosis pancreática (mayor a 50%) y no la sola presencia de la misma, la que determinaría una evolución con complicaciones adicionales y mayor mortalidad.

AIMS: To compare patients with acute necrotizing pancreatitis without any additional complications during their hospital stay (Group A) versus patients with Acute Necrotizing Pancreatitis with additional complications during their hospital stay (Group B) METHODS: Data obtained from a pre-existing base from hospitalized patients with diagnosis of acute necrotizing pancreatitis in the specialized unit of "Unidad de Pancreatitis Aguda Grave del Hospital Nacional Edgardo Rebagliati Martins" between 2000 and 2010. Data included patients with diagnosis of acute necrotizing pancreatitis, of ages 18 and over. RESULTS: Data from 215 patients with acute necrotizing pancreatitis was included. Patients from Group A represented 32% (68) and from Group B 68% (147). Group A had a average of 39 hospitalized days and Group B had an average of 56 days (p=0.01). From Group A 22% had more than 50% of necrosis while 43% of Group B had this extension of necrosis (p <0.05, OR 3.4, IC (1.12-10)). Of the 14 deaths of the population, all part of Group B, 12 of them had more than 50% of necrosis. CONCLUSIONS: Not every patient classified as severe acute pancreatitis, based on the presence of necrosis, behave likewise. It is an extended necrosis, described as more than 50% of pancreatic necrosis, and not the presence itself which will determine additional complications during the course of disease and a greater mortality.

Elevación de creatinina sérica como indicador de necrosis pancreática / Elevation of serum creatinine as an indicator of pancreatic necrosis

La Pancreatitis Aguda (PA) es una patología que se autolimita en el 80% de los casos; estos casos en general evolucionan hacia la recuperación total. Su evolución puede ser de leve a severa. La forma grave varía desde un 10% a un 25% y se asocia con falla orgánica y/o complicaciones locales como necrosis pancreática. En Venezuela, la PA Severa es un importante problema de salud pública, encontrándose entre las primeras 25 causas de muerte. Este estudio plantea la utilización de una prueba de laboratorio ampliamente disponible, de fácil uso e interpretación, para pronosticar la aparición de complicaciones como necrosis pancreática. Objetivo: Determinar la utilidad de la creatinina sérica como factor predictivo de necrosis pancreática en pancreatitis aguda. Materiales y Metodos: Estudio de tipo analítico, transversal y retrospectivo. Se revisaron las historias clínicas de los pacientes que ingresaron al hospital “Dr. Miguel Pérez Carreño”, con diagnóstico de pancreatitis aguda entre 2008 y 2009. Se registró creatinina sérica y se relacionó con la clasificación de severidad tomográfica según Balthazar. Resultados: La población estuvo conformada por 50 casos, de éstos se excluyeron 4, por embarazo o enfermedad renal crónica. Treinta de sexo femenino (65%) y 16 masculino (35%). Edades comprendidas entre 18 a 77 años, con media de 40,2. La estancia hospitalaria media fue de 8,74 días. Del total de 46 pacientes, presentó Balthazar A 63% (n=29), B 17,39% (n=8), C 14,04% (n= 6) y D 6,5% (n=3). No se obtuvo ningún E. Al aplicar un análisis de varianza se observó relación estadística significativa directamente proporcional de la creatinina sérica de ingreso (p=0,001) y de las 48 horas (p=0,001) con el Balthazar y el hematocrito. Conclusiones: La evaluación de los niveles y variaciones de creatinina sérica son de utilidad para predecir la aparición de necrosis pancreática en pacientes con pancreatitis aguda.

Acute Pancreatitis (AP) is a self-limited pathology in 80% of the cases; these cases generally evolve towards total recovery. Its evolution can be mild or severe. The severe form varies from a 10% to a 25%, and is associated with organ failure and/or local complications as pancreatic necrosis. In Venezuela severe AP is an important public health problem, being in the first 25 causes of death. The present study proposes the use of a widely available laboratory test, of easy use and interpretation, to predict the appearance of complications as pancreatic necrosis. Objective: To determine the usefulness of the serum creatinine as predictive factor of pancreatic necrosis in acute pancreatitis. Materials and Methods: An analytic, transversal and retrospective study. Clinical histories of patients admitted to the “Dr. Miguel Perez Carreño” hospital with a diagnosis of acute pancreatitis between years 2008 and 2009 were reviewed. Serum creatinine was registered and compared according to the Balthazar classification of tomographic severity. Results: The sample was comprised by 50 cases, from which 4 were excluded, due to pregnancy or chronic renal disease. Thirty were female (65%) and 16 male (35%). Between the ages of 18 and 77, with mean age of 40,2. The median hospital stay was 8,74 days. From total of 46 patients, 63% had Balthazar A (n=29); B 17.39% (n=8); C 14,04% (n= 6) and D 6.5% (n=3). No Balthazar E was obtained. When applying a variance analysis, a significant statistical relation was observed, directly proportional to the serum creatinine upon admission (p=0,001) and the 48 hours (p=0,001) with the Balthazar and hematocrit. Conclusions: The evaluation of the levels and variations of serum creatinine is a useful tool for predicting the appearance of pancreatic necrosis in patients with acute pancreatitis.

Regulation of omega-3 fish oil emulsion on the SIRS during the initial stage of severe acute pancreatitis / 华中科技大学学报（医学）（英德文版）

The aim of this study was to explore the effects of parenteral supplementation with omega-3 fish oil emulsion (Omegaven) on systemic inflammatory response syndrome (SIRS) during the initial stage of severe acute pancreatitis (SAP). In a prospective, randomized and controlled trial, 60 patients with SAP were randomized either to treat with conventional therapy (Con group, n=30) or conventional therapy plus intravenous supplementation with omega-3 fish oil emulsion 0.2 g/kg every day (FO group, n=30). The effects were analyzed by the SIRS-related indexes. The results showed that APACHE-II scores in FO group were significantly lower, and the gap increased much farther after the 4th day than those in Con group (P<0.05). Fluid equilibrium time became shorter markedly in FO group than in Con group (5.1+/-2.2 days vs 8.4+/-2.3 days). In FO group, SIRS scores were markedly decreased and the SIRS state vanished after the 4th day; Plasma level of TNF-alpha was significantly reduced, while IL-10 decreased markedly, most prominently between the 4th and 7th day, and the ratio of IL-10/TNF-alpha raised as compared with Con group (P<0.05). During the initial stage of SAP, parenteral supplementation with omega-3 fish oil emulsion could efficiently lower the magnitude and persistence time of the SIRS, markedly retrieve the unbalance of the pro-/anti-inflammatory cytokines, improve severe condition of illness and may provide a new way to regulate the SIRS.

Curso de atualização em emergências médicas: aula 15: pancreatite aguda: diagnóstico e terapêutica / Course of updating in medical emergencies: class 15: acute pancreatitis: diagnosis and therapeutics

A evolução clínica de um episódio de pancreatite aguda varia de um quadro autolimitado, benigno, restrito ao abdome, a uma doença sistêmica, grave, de evolução imprevisível e por vezes fatal. Embora a maioria se apresente de forma benigna (80 por cento a 90 por cento), também denominada pancreatite aguda leve, cerca de 10 por cento a 20 por cento mostram-se potencialmente graves e têm como marco principal a necrose pancreática e(ou) peripancreática. Apesar de inúmeras etiologias, 80 por cento a 90 por cento são decorrentes de colelitíase, em especial microlitíase, e alcoolismo. A mortalidade é desprezível na forma leve da doença, mas preocupante em sua forma grave, com índices variando de 20 por cento a 40 por cento. A falência múltipla de órgãos e a infecção sistêmica (sepse) são os grandes responsáveis por esta alta letalidade na PA necrosante. O melhor conhecimento das formas evolutivas, a aquisição de métodos de imagem diagnósticos e terapêuticos, o setor especializado de terapia intensiva e a maior experiência de equipes interdisciplinares têm promovido uma queda significativa na morbiletalidade.

The clinical evolution of an episode of acute pancreatitis vary from self-limited condition, benign, restrict to the abdomen to a systematic disease, severe, of an inexact and some time fatal evolution. Although most of them appear in a benign form (80 percent - 90 percent), about 10 percent - 20 percent of the also called mild acute pancreatitis is potentially severe and has its beginning as a pancreatic and(or) peripancreatic necrosis. Despite many etiologies, 80 percent - 90 percent are due to cholelithiasis, especially microlithiasis and alcoholism. Mortality is insignificant in the mild form of the disease, but worrisome when it comes to severe acute pancreatitis, when the indexes vary in 20 percent -40 percent. Multiple organ failure and systemic infection (sepsis) are the most responsible for the high mortality rate of the necrotizing PA. Knowing better the evolutionary forms aquisition of diagnostic and therapeutic image methods, specializes department in critical care and a more experienced and interdisciplinary staff have promoted a significant decrease in morbilethality.

Two Cases of Colonic Obstruction after Acute Pancreatitis / 대한소화기학회지

Several forms of colonic complications are rarely observed during the clinical course of acute pancreatitis, and potentially fatal in some cases. Colonic lesions associated with acute pancreatitis can be divided into several groups from a pathogenic point of view. Possible pathogenesis includes 1) spread of pancreatic enzymes through the retroperitoneum to mesocolon, causing pericolitis, 2) external inflammatory compression by mesocolic mass secondary to necrosis of fatty tissue, and 3) hypotension due to shock, and thrombosis of mesenteric arteries. These might lead to colonic infarction, fistula formation, perforation, and obstruction during follow-up. We report two cases of colonic obstruction following acute pancreatitis with possible different mechanisms and review Korean cases. One patient developed colonic obstruction due to severe necrotizing pancreatitis, possibly as a result of pericolitis, and the other developed stenosis as a result of ischemic colitis induced by acute pancreatitis.

Outcome of Intensive Medical Treatments in Patients with Infected Severe Necrotizing Pancreatitis / 대한소화기학회지

BACKGROUND/AIMS: Infection of pancreatic necrosis is one of the leading cause of death in patients with severe necrotizing pancreatits. Because of high mortality rate up to 50%, immediate surgical debridement including pancreatectomy is recommended. However, early surgical treatment still showed high mortality rate and better treatment strategy is required. This study was conducted to evaluate the outcomes of early intensive non-surgical treatments in patients with infected necrotizing pancreatitis. METHODS: This study was based on retrospective analysis of 71 patients with acute severe necrotizing pancreatitis (APACHE II score>or=8, or Ranson's score>or=3, and pancreatic necrosis on CT scan), who were admitted to medical center during past 16 years. Infection of pancreatic necrosis was confirmed by fine needle aspiration, and early intensive medical treatments comprised of prophylactic antibiotics coverage, fluid resuscitation, organ preserving supportive measures, and percutaneous catheter drainage were carried out. RESULTS: Among the enrolled patients, infections were suspected in 46 patients, but fine needle aspirations were done only in 32 patients. In 21 patients, infections of necrotic tissue were confirmed by bacteriology, while other 11 patients showed no evidence of bacterial growth. Of 21 patients with infected necrosis, initial surgical interventions were performed in 2 patients, while initial medical treatments were performed in 19 patients. The success rate of medical treatment group in infected necrotizing pancreatitis was 79% (15/19). The mortality rate of medical treatment group and surgical treatment group was 5% (1/19) and 50% (1/2). CONCLUSIONS: Early intensive medical treatment seems to be a good therapeutic strategy, even if the infection has developed in pancreatic necrosis. Further prospective randomized studies are required to confirm this finding.

Frecuencia de falla orgánica en la pancreatitis aguda necrótica / Frecuency of organic failure in acute necrosis pancreatitis

Introducción: La pancreatitis aguda se clasifica como severa por la presencia de necrosis glandular o falla orgánica. Sin embargo, ambas condiciones no son simultáneas. En este estudio determinamos la frecuencia de falla orgánica en pacientes con necrosis pancreática por pancreatitis aguda. Material y Métodos: Se realizó un estudio retrospectivo, transversal, descriptivo y observacional. Se incluyeron los casos de necrosis pancreática por pancreatitis aguda presentados del 1 de enero de 1996 al 31 de diciembre de 2000. Se determinó la presencia de falla orgánica, así como edades, sexo, etiología, estado nutricional, criterios de Ranson, cirugías realizadas y mortalidad. Resultados: De los pacientes con necrosis pancreática, 45% desarrolló falla orgánica. En ellos predominó el sexo masculino y la realización de alguna cirugía. De los pacientes con falla orgánica, 92% la presentó al ingreso; el sistema afectado más frecuente fue el circulatorio, seguido por el pulmonar y el renal. Los pacientes con falla orgánica tuvieron mortalidad de 88%. Las causas de muerte fueron SIRPA y choque irreversible. Discusión: La relación entre necrosis y falla orgánica no es clara. Existen factores a considerar tales como la muerte de tejido pancreático por apoptosis, que limita el daño y la necrosis que lo favorece. La hipoperfusión tisular puede ser determinante entre estas dos formas de lesión.

Introduction: The acute pancreatitis is classified as severe by the presence of glandular necrosis or organic failure. However both conditions are not simultaneous. We determine the frequency of organic failure in patients with pancreatic necrosis for acute pancreatitis. Material and Methods: A study retrospective, transverse, descriptive and observational is carried. Were included the cases of pancreatic necrosis by acute pancreatitis presented of January 1 from 1996 to December 31 2000. The presence of organic failure was determined, as well as ages, sex, etiology, nutritional state, Ranson's criteria, surgeries carried and mortality. Results: 45% of the patients with necrosis pancreatic development organic failure. The masculine sex and the realization of some surgery predominated in them. 92% of the patients with organic failure presents it to the admission, the system circulatory was the more frequently affected, continued by the respiratory and the renal. The patients with organic failure had a mortality of 88% against 0% of those that didn 't present it. The SIRPA and irreversible shock were the causes of death. Discussion: Not is clear the relationship between necrosis and organic failure. The death of pancreatic tissue for apoptosis, that limits the damage and the necrosis, that it favors, is factors to consider. The hypoperfusion tissular can be the determinant among these two lesion forms.

Experience in diagnosis and treatment of bleeding complications in severe acute pancreatitis by TAE / 华中科技大学学报（医学）（英德文版）

The experience in diagnosis and treatment of bleeding complications in severe acute pancreatitis (SAP) by transcatheter arterial embolization was summarized. The clinical data of 19 SAP patients complicated with intra-abdominal bleeding in our hospital from Jan. 2000 to Jan. 2003 were analyzed retrospectively and the therapeutic outcome of TAE was evaluated statistically. The results showed that the short-term successful rate of hemostasis by TAE was 89.5% (17/19), the incidence of re-bleeding after TAE was 36.8% (7/19) and the successful rate of hemostatis by second TAE was 71.4% (5/7). It was concluded that the intra-abdominal bleeding in SAP was mainly caused by the rupture of erosive/infected pseudoaneurysm. Mostly, the broken vessels were splenic artery and gastroduodenal artery; In terms of emergence hemostatis, TAE is the most effective method. Surgical hemostasis is necessary if hemostasis by TAE is failed or re-bleeding occurs after TAE.