Desbridamiento retroperitoneal video asistido: una nueva técnica quirúrgica para una vieja patología, la pancreatitis aguda severa presentación de caso clínico / Video-assisted retroperitoneal debridement: a new surgical technique for an old pathology, severe acute pancreatitis clinical case presentation

INTRODUCCIÓN: el desbridamiento retroperitoneal video asistido (DRVA) es una técnica mínimamente invasiva usada para el tratamiento de la necrosis pancreática infectada (NPI). MATERIAL Y MÉTODO: reporte de caso. RESULTADOS: se presenta un caso de pancreatitis aguda severa tratada con DRVA en una paciente femenina de 43 años, con un cuadro clínico de 5 días de evolución caracterizado por dolor abdominal espasmódico en hipocondrio derecho, de moderada intensidad, irradiado a epigastrio y en cinturón a ambos flancos. La paciente recibió atención privada en dos centros previos al ingreso al nuestro. Al ingreso, en el laboratorio, presenta leucocitosis y desvió izquierdo, amilasémia y lipasémia altas. Se realizaron tomografías contrastadas y punciones guiadas por TAC y DRVA cuando se evidencia necrosis amurallada. Se describe la técnica quirúrgica. Súbitamente la paciente presenta insuficiencia respiratoria y datos compatibles con tromboembolia pulmonar y fallece. CONCLUSIÓN: bajo la visión de terapia escalonada, el desbridamiento retroperitoneal video asistido va ganando adeptos en el manejo de la Pancreatitis Aguda Severa

BACKGROUND: video-assisted retroperitoneal debridement (VARD) is a minimally invasive technique used for the treatment of infected necrotizing pancreatitis. MATERIAL AND METHODS: case report. RESULTS: a case of severe necrotizing pancreatitis is presented in a 43 years old female patient, with 5 days clinical evolution with spasmodic abdominal pain in epigastrium and right hypochondrium of moderate intensity, irradiated to both flanks in belt. The patient received private care in two centers upon the admission in our hospital. In the laboratory at the admission, she showed leukocytosis and left deviation, high level in amylase and lipase. Contrasted enhanced tomography and guided punctures were realized and VARD were considered when evidence of wall of necrosis was observed in scanner. The surgical technique is described. Suddenly the patient presented acute respiratory failure with massive pulmonary thromboembolism and died. CONCLUSION: under the step-up approach vision, the video-assisted retroperitoneal debridement is gaining popularity in the management of the acute necrotizing pancreatitis

Efficacy of different enteral nutrition drugs for severe acute pancreatitis and their gastrointestinal tolerance / 中国药房

OBJECTIVE To compare the efficacy of different enteral nutrition （EN） drugs for severe acute pancreatitis （SAP） and their gastrointestinal tolerance. METHODS A total of 118 SAP patients admitted to the Pancreatic Center of Jiangsu Provincial People’s Hospital from January 1， 2022 to June 30， 2023 were collected and divided into short-peptide EN drugs （SP） group （41 cases）， dietary fiber-free intact protein EN drugs （TP-MCT） group （40 cases） and dietary fiber-containing intact protein EN drugs （TPF-DM） group （37 cases） according to the types of EN. All three groups of patients were given continuous pumps of EN drugs via nasal feeding for 24 hours， with a target energy dose of 25-30 kcal/kg. The blood nutritional indexes [albumin （ALB）， total protein （TP）， hemoglobin （Hb）， globulin （GLB）]， inflammation indexes [white blood cells （WBC）， percentage of neutrophils （N%）， procalcitonin （PCT）， C-reactive protein （CRP）， interleukin-6 （IL-6）]， clinical outcomes indexes [time of stay in the intensive care unit （ICU）， length of hospital stay， duration of resuming oral diet， the rate of cases without improvement， mortality rate] and the occurrence of gastrointestinal tolerance were collected from 3 groups before medication and 7 d after medication. RESULTS After treatment， ALB and TP in 3 groups were significantly higher than before treatment （P＜0.05）； CRP and N% of 3 groups， PCT of TP-MCT group and IL-6 of SP group were significantly lower than corresponding group before medication （P＜ 0.05）； PCT of TP-MCT group and IL-6 of SP group were significantly lower than those of other two groups at corresponding period （P＜0.05）. There were no statistical significances in ALB， TP， CRP or N% among the three groups after medication， and in Hb， GLB or WBC among the three groups before and after treatment （P＞0.05）. There was no significant difference in clinical outcome indexes among 3 groups （P＞0.05）. The incidence of gastrointestinal adverse reactions in the TP-MCT group was the lowest （32.50%）， and significantly lower than those in the SP group （46.34%） and TPF-DM group （48.65%） （P＜0.05）. CONCLUSIONS Different EN preparations can improve the nutritional status and reduce the inflammatory response in SAP patients to different extents， among which SP and TP-MCT are more effective， and TP-MCT shows the better gastrointestinal tolerance.

Predictive value of diaphragm thickening fraction and intra-abdominal pressure monitoring-oriented risk prediction model for weaning failure in patients with severe acute pancreatitis / 中华危重病急救医学

Objective:To establish a risk prediction model dominated by diaphragm thickening fraction (DTF) and intra-abdominal pressure (IAP) monitoring, and to explore the predictive value of the model for weaning failure in patients with severe acute pancreatitis (SAP).Methods:A prospective research was conducted. Sixty-three patients undergoing invasive mechanical ventilation treatment who diagnosed with SAP admitted to intensive care unit of the First Affiliated Hospital of Jinzhou Medical University from August 2020 to October 2021 were enrolled. The spontaneous breathing trial (SBT) was carried out when the clinical weaning criteria was met. The stable cardiovascular status, good pulmonary function, no chest and abdominal contradictory movement, and adequate oxygenation were defined as successful weaning. Otherwise, it was defined as failure weaning. The clinical indicators such as SBT 30-minure DTF, IAP, tidal volume (VT), respiratory rate (RR), body mass index (BMI), and blood lactic acid (Lac) were compared between the weaning success group and the weaning failure group. The indicators with statistically significant differences in the single-factor analysis were included in the secondary multivariable Logistic regression analysis to establish a risk prediction model. The correlation between the DTF and IAP at 30 minutes of SBT was analyzed. Receiver operator characteristic curve (ROC curve) was drawn to analyze the predictive value of the risk prediction model for SAP patient withdrawal failure at 30 minutes of SBT.Results:Finally, 63 patients with SAP were enrolled. Among the 63 patients, 42 were successfully weaned and 21 failed. There were no significant differences in age, gender, and oxygenation index (PaO 2/FiO 2), sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score at admission between the two groups, indicating that the data in the two groups were comparable. Compared with the weaning success group, IAP, RR, BMI and Lac at 30 minutes of SBT in the weaning failure group were significantly increased [IAP (mmHg, 1 mmHg≈0.133 kPa): 14.05±3.79 vs. 12.12±3.36, RR (times/min): 25.43±8.10 vs. 22.02±5.05, BMI (kg/m 2): 23.71±2.80 vs. 21.74±3.79, Lac (mmol/L): 5.27±1.69 vs. 4.55±1.09, all P < 0.05], while DTF and VT were significantly decreased [DTF: (29.76±3.45)% vs. (31.86±3.67)%, VT (mL): 379.00±98.74 vs. 413.60±33.68, both P < 0.05]. Secondary multivariable Logistic regression analysis showed that DTF [odds ratio ( OR) = 0.758, 95% confidence interval (95% CI) was 0.584-0.983, P = 0.037], IAP ( OR = 1.276, 95% CI was 1.025-1.582, P = 0.029), and RR ( OR = 1.145, 95% CI was 1.014-1.294, P = 0.029) were independent risk factors for SBT withdrawal failure in 30 minutes in SAP patients. The above risk factors were used to establish the risk prediction model of aircraft withdrawal failure at 30 minutes of SBT: Logit P = -0.237-0.277×DTF+0.242×IAP+0.136×RR. Pearson correlation analysis showed that SBT 30-minute DTF was significantly correlated with IAP in SAP patients, and showed a significant positive correlation ( r = 0.313, P = 0.012). The ROC curve analysis results showed that area under the ROC curve (AUC) of the risk prediction model for SAP patient withdrawal failure at 30 minutes of SBT was 0.716, 95% CI was 0.559-0.873, P = 0.003, with the sensitivity of 85.7% and the specificity of 78.6%. Conclusions:DTF, IAP and RR were independent risk factors for SBT withdrawal failure in 30 minutes in SAP patients. The DTF and IAP monitoring-oriented risk prediction model based on the above three variables has a good predictive value for weaning failure in patients with SAP.

Construction and evaluation of a prognostic model for severe acute pancreatitis based on CT scores and inflammatory factors / 中华危重病急救医学

Objective:To construct a prognostic model for severe acute pancreatitis (SAP) based on CT scores and inflammatory factors, and to evaluate its efficacy.Methods:128 patients with SAP diagnosed admitted to the First Hospital Affiliated to Hebei North College from March 2019 to December 2021 were enrolled and given Ulinastatin combined with continuous blood purification therapy. The levels of C-reactive protein (CRP), procalcitonin (PCT), interleukins (IL-6, IL-8), tumor necrosis factor-α (TNF-α), and D-dimer were measured before and on the third day of treatment. An abdominal CT was performed on the third day of treatment to assess the modified CT severity index (MCTSI) and extra-pancreatic inflammatory CT score (EPIC). Patients were divided into the survival group ( n = 94) and the death group ( n = 34) according to the 28-day survival prognosis after admission. The risk factors for the SAP prognosis were analyzed using Logistic regression, which was then used to build nomogram regression models. The value of the model was evaluated using the concordance index (C-index), calibration curves and decision curve analysis (DCA). Results:Before treatment, the levels of CRP, PCT, IL-6, IL-8 and D-dimer in the death group were higher than those in the survival group. After treatment, the levels of IL-6, IL-8 and TNF-α in the death group were higher than those in the survival group. MCTSI and EPIC scores in the survival group were lower than those in the death group. Logistic regression analysis shows that, pre-treatment CRP > 140.70 mg/L, D-dimer > 2.00 mg/L, and post-treatment IL-6 > 31.28 ng/L, IL-8 > 31.04 ng/L, TNF-α > 31.04 ng/L, and MCTSI > 8 points were all independent risk factors for SAP prognosis [odds ratios ( OR) and 95% confidence intervals (95% CI) were 8.939 (1.792-44.575), 6.369 (1.368-29.640), 8.546 (1.664-43.896), 5.239 (1.108-24.769), 4.808 (1.126-20.525), 18.569 (3.931-87.725), all P < 0.05]. Model 1 (consisting of pre-treatment CRP, D-dimer, and post-treatment IL-6, IL-8 and TNF-α) had a lower C-index than that model 2 (consisting of pre-treatment CRP, D-dimer, and post-treatment IL-6, IL-8 and TNF-α, and MCTSI; 0.988 vs. 0.995). The mean absolute error (MAE) and mean square error (MSE) of model 1 (0.034, 0.003) were higher than those of model 2 (0.017, 0.001). When the threshold probability was in the range of 0-0.66 or 0.72-1.00, the net benefit of model 1 was lower than that of model 2. When the threshold probability was in the range of 0.66-0.72, the net benefit of model 1 was higher than that of model 2. In addition, model 2 had a higher C-index than acute physiology and chronic health evaluationⅡ (APACHE Ⅱ) and bedside index of acute pancreatitis severity (BISAP, 0.995 vs. 0.833, 0.751). Model 2 had a lower MAE (0.017) and MSE (0.001) than APACHEⅡ (0.041, 0.002). Model 2 had a lower MAE than BISAP (0.025). Model 2 had a higher net benefit than both APACHEⅡ and BISAP. Conclusion:The prognostic assessment model of SAP consisting of pre-treatment CRP, D-dimer, and post-treatment IL-6, IL-8 and TNF-α, and MCTSI has high discrimination, precision and clinical application value, and is superior to APACHEⅡ and BISAP.

The formulation of the best evidence for early fluid resuscitation management of severe acute pancreatitis patients / 中华胰腺病杂志

Objective:To establish the best evidence-based approach for early fluid resuscitation management in patients with severe acute pancreatitis (SAP).Methods:A literature search was conducted utilizing evidence-based nursing methods to identify relevant evidence on the management of early fluid resuscitation in patients with SAP. The search followed the hierarchical order of the " 6S" evidence pyramid, including databases such as China National Knowledge Infrastructure (CNKI), China Biomedical Literature Database (SinoMed), Wanfang Database, UpToDate, NICE, RNAO Guidelines Network, Pancreatology International, WHO Association Website, JBI, Cochrane, PubMed, EMBASE, and CINAHL. The search was limited to articles published from the establishment of each database to March 2022. The literature quality evaluation tools and an evidence pre-grading system from the JBI Evidence-Based Health Care Center were employed to assess the quality of the literature included in the study. Additionally, the FAME structure was utilized to evaluate the feasibility, appropriateness, clinical significance, and validity of the evidence.Results:Nine articles were finally incorporated into the analysis, including four guidelines, one evidence summary, two systematic reviews, and two expert consensus articles. 21 pieces of evidence pertaining to early fluid resuscitation management in patients with SAP was summarized, encompassing five key aspects: resuscitation timing, type of fluid infusion, total volume and speed of fluid infusion, dynamic monitoring, and fluid resuscitation goals. It was advisable for patients diagnosed with SAP to promptly receive fluid resuscitation, ideally within 72 hours of diagnosis. The initial choice for fluid resuscitation was lactated Ringer′s solution, with the addition of human albumin as a supplementary colloid solution. The quantity of fluid administered within the first 24 hours of rehydration should constitute approximately 33.3% of the total rehydration volume within the 72 hours time-frame. In the case of patients experiencing early shock or dehydration, it was advised that the fluid rate administered should be 5-10 ml·kg -1·h -1 within the first 24 hours of admission. Additionally, an infusion of 20 ml/kg of fluid can be administered within the initial 30-45 minutes. It was recommended to assess the adequacy of early fluid resuscitation every 4-6 hours, ensuring that the resuscitation objective could meet at least two of the following criteria: urine output of 0.5-1 ml·kg -1·h -1, mean arterial pressure of 65-85 mmHg, central venous pressure of 8-12 mmHg, heart rate below 120 beats/min, central venous oxygen saturation of at least 70%, and a decrease in hematocrit levels to 30%-35%. Conclusions:The most compelling evidence supporting the implementation of early fluid resuscitation management in patients with SAP is derived from an evidence-based nursing approach, which could effectively improve patient care outcomes.

Early assessment and treatment of severe acute pancreatitis in children / 中国小儿急救医学

Due to the high mortality rate of severe acute pancreatitis in children, early and adequate evaluation of children with acute pancreatitis, early identification of risk factors leading to severe acute pancreatitis, and active intervention therapy have important impacts on the outcome of acute pancreatitis.This review summarized clinical guidelines or consensus worldwide, and elaborated the diagnosis and treatment of severe acute pancreatitis in children from the aspects of epidemiology, clinical features, early screening evaluation and treatment measures.

Study on the consistency and correlation of different methods for measuring energy consumption in patients with severe acute pancreatitis / 中华消化杂志

Objective:To analyze the consistency and correlation of indirect calorimetry (IC) and Harris-Benedict estimation method (H-B) in measuring energy consumption in patients with severe acute pancreatitis (SAP), as well as the characteristics of energy metabolism at resting state of SAP patients with different etiologies, and so as to guide the formulation of clinical energy nutrition support program.Methods:From February 1 to December 31, 2019, 61 SAP patients admitted into the intensive care unit of the First Affiliated Hospital of Nanchang University were enrolled. Collected relevant data of patients, such as the etiology of SAP, whether mechanical ventilation was needed, as well as the metabolic status. All SAP patients accepted IC test on the first day after admission to intensive care unit. According to the energy consumption measured by IC (hereinafter referred to as IC value) and the energy consumption measured by H-B (hereinafter referred to as H-B value), SAP patients were determined to be in high, normal or low metabolic state. Bland-Altman method and Pearson linear regression were used to analyze the consistency and correlation of the two methods in measuring energy consumption, and the linear equation was fitted. Paired t test was used for statistical analysis. Results:Among the 61 SAP patients, 13 cases were biliary SAP, 30 cases were hyperlipidemic SAP, 6 cases were alcoholic SAP, and 12 cases were SAP of other causes or unknown causes. Nineteen cases needed mechanical ventilation and 42 cases did not need mechanical ventilation. There were 70.5% (43/61) of SAP patients in high metabolic state, 13.1%(8/61) of SAP patients in normal metabolic state, and 16.4% (10/61) of SAP patients in low metabolic state. The IC value in 61 SAP patients was higher than H-B value((8 604.7±367.8) kJ/d vs. (6 491.2±133.7) kJ/d), and the difference was statistically significant ( t=5.95, P<0.001). The IC value in patients with hyperlipidemic, alcoholic and biliary SAP was (8 815.2±537.9), (7 631.2±890.5), and (8 108.0±933.1) kJ/d, respectively, and the H-B value was (6 869.6±204.5), (5 916.8±153.7), and (5 974.2±200.9) kJ/d, respectively. The IC value in patients with biliary or hyperlipidemic SAP were higher than H-B value, and the differences were statistically significant( t=2.29 and 3.38, both P<0.05). The IC value and H-B value in SAP patients with mechanical ventilation and without mechanical ventilation were (10 485.0±741.1) and (6 462.6±222.8) kJ/d, (6 595.1±364.7) and (6 503.2±166.7) kJ/d, respectively. The IC value in SAP patients with mechanical ventilation was higher than H-B value and the IC value in SAP patients without mechanical ventilation, and the differences were statistically significant ( t=4.71 and 5.20, both P<0.001). The consistency analyzed by Bland-Altman method showed that the two methods had obvious biases, and the average bias value was 92.2 kJ/d. The result of Pearson linear regression analysis indicated that there was a linear relationship between two methods ( r=0.44, P<0.001). The linear equation fitted by the univariate regression was Y=1.240 6 X+ 154.42, in which X was the H-B value and Y was the IC value. Conclusions:SAP patients are mostly in a hypermetabolic state in the early stages of the disease. The IC value is higher than H-B value, and it is recommended to use IC to measure energy consumption in SAP patients.

Clinical value of activin A in early identification of moderate and severe acute pancreatitis: a prospective study / 中华危重病急救医学

Objective:To explore the value of serum activin A (ACT-A) level in early identification of moderate and severe acute pancreatitis (AP).Methods:A prospective case control study was conducted. A total of 120 patients with AP admitted to department of hepatobiliary surgery of Affiliated Nanhua Hospital of Hengyang Medical College of University of South China between October 2020 and April 2022 were recruited. According to the revised Atlanta classification, all patients were classified into mild AP group and moderate-to-severe AP group. The blood samples within 24 hours of onset were drawn, and the serum ACT-A and C-reactive protein (CRP) levels were detected by enzyme-linked immunosorbent assay (ELISA). The Ranson score and the modified CT severity index (MCTSI) were performed. Pearson correlation method was used to analyze the correlation of various parameters. The receiver operator characteristic curve (ROC curve) was plotted to analyze the predictive value of ACT-A and CRP for moderate-to-severe AP.Results:A total of 120 patients with AP were enrolled, including 83 patients with mild AP and 37 patients with moderate-to-severe AP. Serum ACT-A and CRP levels within 24 hours of onset in the moderate-to-severe AP group were significantly higher than those in the mild AP group [ACT-A (ng/L): 140.4±37.7 vs. 53.9±30.5, lg CRP: 1.42±0.91 vs. 0.77±0.70, both P < 0.01], and the Ranson score and MCTSI score were also significantly higher than those in the mild AP group (Ranson score: 5.3±1.3 vs. 1.8±1.6, MCTSI score: 5.5±1.0 vs. 2.7±1.2, both P < 0.01). Correlation analysis showed that the serum ACT-A level was positively correlated with serum CRP level, Ranson score and MCTSI score ( R2 value was 0.272, 0.841, 0.616, respectively, all P < 0.05). ROC curve analysis showed that the serum ACT-A, CRP and Ranson score had predictive value for moderate-to-severe AP. The area under the ROC curve (AUC) was 0.948 [95% confidence interval (95% CI) was 0.909-0.986], 0.711 (95% CI was 0.606-0.815), 0.946 (95% CI was 0.910-0.982), respectively. When serum ACT-A > 112.6 ng/L, the sensitivity and specificity of predicting moderate-to-severe AP were 78.38% and 96.39%, respectively, which was better than serum CRP with sensitivity and specificity of 72.92% and 66.27%, respectively, and the specificity was better than Ranson score (71.08%). Conclusion:ACT-A can be detected in the early stage of AP, and it is positively correlated with the disease severity, which can early identify moderate-to-severe AP.

Clinical effect of fluid resuscitation guided by intra-abdominal pressure and oxygenation index for severe acute pancreatitis patients / 中华危重病急救医学

Objective:To investigate the effect of the liquid resuscitation therapy strategy using intra-abdominal pressure (IAP) and oxygenation index (PaO 2/FiO 2) as the end point in patients with severe acute pancreatitis (SAP). Methods:A retrospective study was performed, including 84 patients with SAP in emergency intensive care unit of Qingzhou Hospital Affiliated to Shandong First Medical University from January 2018 to August 2021. According to the status of fluid balance at admission, all patients were divided into the positive fluid balance group (43 cases) and the negative fluid balance group (41 cases). The clinical data including gender, age, etiology, underlying disease, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) and sequential organ failure assessment (SOFA) of all patients were collected. Fluid balance, PaO 2/FiO 2, IAP, compliance rate, new mechanical ventilation rate and overall hospital stay of 1 week after admission were recorded and compared between the two groups. Results:After 72 hours of treatment, the cumulative fluid balance was (5 219.5±1 038.4) mL in the positive fluid balance group; IAP was higher than that before treatment [mmHg (1 mmHg≈0.133 kPa): 11.9±2.0 vs. 11.7±2.1], but no significant difference was found ( P > 0.05); PaO 2/FiO 2 was significantly higher than that before treatment (mmHg: 299.8±51.4 vs. 220.5±50.4, P < 0.05). After 72 hours of treatment, the cumulative fluid balance in negative fluid balance group was (-3 542.4±1 310.6) mL; IAP was significantly lower than before treatment (mmHg: 11.4±1.8 vs. 15.2±1.9, P < 0.05); PaO 2/FiO 2 was significantly higher than that before treatment (mmHg: 309.9±50.9 vs. 215.4±49.7, P < 0.05). In the fluid resuscitation goals, after 72 hours of treatment, the compliance rate in the negative fluid balance group was significantly higher than that in the positive fluid balance group [82.93% (34/41) vs. 62.79% (27/43), P < 0.05]; 1 week after admission, the new mechanical ventilation rate in the negative fluid balance group was significantly lower than that in the positive fluid balance group [21.95% (9/41) vs. 41.86% (18/43), P < 0.05]; however, there was no significant difference in overall hospital stay between the two groups (days: 41.2±10.9 vs. 39.1±11.5, P > 0.05). After treatment, 70 patients survived and 14 patients died (including 9 cases in the positive fluid balance group and 5 cases in the negative fluid balance group). Conclusions:Using IAP and PaO 2/FiO 2 to guide liquid therapy could result in effective fluid resuscitation in SAP. The treatment strategy effectively improved prognosis of patients with SAP.

Ultrasound-guided enema for a case of severe acute pancreatitis patient complicated with intra-abdominal hypertension / 中国实用护理杂志

objective:This paper summarizes the nursing care of a case of severe acute pancreatitis complicated with intra-abdominal hypertension by ultrasonic-guided enema.Methods:One patient with severe acute pancreatitis internal high pressure from February 28, 2021 in Shandong Provincial Hospital Affiliated to Shandong First Medical University setting indiidualized enema scheme, advantage of the characteristics of ultrasonic visualization, before and after the enema examine case of intestinal cleaning and waste water accumulation, enema, positioning enemator catheter and cutting-edge position, ensure the accuracy of the enema, normal irrigation using configuration at the same time, the relaxation anal sphincter and so on, to observe the therapeutic effects enema.Results:After careful treatment and nursing, the patient achieved satisfactory results of exhaust and defecation, enema, abdominal distention improved, intra-abdominal pressure returned to normal, 10 days later, the condition was stable and transferred to the general ward.Conclusions:For the nursing of patients with severe acute pancreatitis complicated with intra-abdominal hypertension, it is particularly important to reduce intra-abdominal pressure by enema. Nurses should make reasonable use of new technology to implement individualized enema nursing, promote the excretion of stool, reduce intra-abdominal pressure, and facilitate the early recovery of the disease.

The prognostic value of neutrophil to lymphocyte ratio and platelet to lymphocyte ratio combined with BISAP score for severe hypertriglyceridemia pancreatitis / 中华急诊医学杂志

Objective:To explore the value of neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) combined with bedside index for severity in acute pancreatitis (BISAP) score in predicting severe acute pancreatitis (SAP) in patients with hypertriglyceridemia pancreatitis (HTGP).Methods:Patients who met the diagnostic criteria of HTGP were retrospectively collected in the Emergency Department of Peking University People's Hospital from January to December in 2019. Patients were assigned to two groups according to the severity of acute pancreatitis: the mild acute pancreatitis group and severe acute pancreatitis (SAP) group. Blood samples were taken within 24 h after the onset of HTGP for analysis. White blood cell count, neutrophil count, lymphocyte count, and other laboratory indicators were detected. BISAP score was performed, and NLR and PLR were calculated in all patients within 24 h of the onset of HTGP. Comparison of various indicators was performed in the two groups. The risk factors of SAP patients with HTGP were analyzed by Logistic regression. The correlation of risk factors was analyzed by correlation. The receiver operating characteristic (ROC) curve was drawn, and the optimal thresholds of NLR and PLR were calculated respectively. The BISAP score, NLR combined with BISAP score (BN score), PLR combined with BISAP score (BP score), and NLR, PLR combined with BISAP score (BNP score) were compared respectively to predict SAP in patients with HTGP.Results:A total of 82 patients were collected. There were significant differences in the proportion of patients with fever, NLR, PLR, lactate dehydrogenase, urea nitrogen, Ranson score, acute physiology and chronic health evaluationⅡ(APACHEⅡ) score and BISAP score between the two groups (all P<0.05). Logistic regression analysis showed that NLR ( OR=1.859, 95% CI: 1.385-2.497, P<0.001), PLR ( OR=1.074, 95% CI: 1.036-1.112, P<0.001) and BISAP score ( OR=2.880, 95% CI: 1.578-5.258, P=0.001) were risk factors for severe HTGP. Correlation analysis confirmed that NLR and PLR were positively correlated with BISAP, APACHE Ⅱand Ranson score. The AUC of BISAP score, BN score, BP score and BNP score for predicting SAP in HTGP were 0.865 (95% CI: 0.787-0.943), 0.925 (95% CI: 0.869-0.981),0.930 (95% CI: 0.885-0.987), and 0.936 (95% CI: 0.874-0.986). Conclusions:NLR and PLR combined with BISAP score has a higher sensitivity to predict the severity of HTGP, which can predict severe pancreatitis within 24 h of the onset of HTGP, so that providing better guidance for treatment.

Effect of the timing of peripancreatic fluid drainage on prognosis in patients with severe acute pancreatitis: a two-center clinical retrospective study / 中华急诊医学杂志

Objective:To evaluate the effect of the timing of peripancreatic drainage on the survival outcome of patients with severe acute pancreatitis (SAP).Methods:This retrospective study included 271 patients with SAP admitted to two tertiary hospitals from January 2015 to December 2019. The Acute Physiology and Chronic Health EvaluationⅡ score (APACHEⅡ), Sequential Organ Failure Assessment score (SOFA), computed tomography (CT) grade, peripancreatic drainage situations, and survival outcome of patients were recorded. Patients were divided into the early and non-early peripancreatic catheter drainage groups (EPCD and non-EPCD). The data were analyzed using the Cox proportional hazard model for propensity score matching (PSM) and stratification.Results:After PSM, the 30-day and 90-day risk of death between the EPCD and non-EPCD groups were significantly different (0.134, 95% CI: 0.029-0.576, P=0.007; 0.166, 95% CI: 0.044-0.631, P=0.008, respectively). Furthermore, stratified analysis revealed significant differences in 30-day and 90-day risk of death between the EPCD and non-EPCD groups when the SOFA score was≥4 or the APACHEⅡ score was ≥8. Conclusions:For patients with SAP with SOFA score ≥4 or APACHEⅡ score≥8, early peripancreatic drainage can reduce the risk of death, but CT grading is not helpful for the decision-making of drainage timing in patients with SAP.

Protective effect of hydroxysafflor yellow A on lung injury associated with severe acute pancreatitis in mice / 中华急诊医学杂志

Objective:To investigate the protective effect and mechanism of hydroxysafflor yellow A (HSYA) on severe acute pancreatitis (SAP) related lung injury.Methods:Fifty mice were randomly (random number) divided into five groups: the sham-operated group, SAP group and different doses (20, 40 and 80 mg/kg) of HSYA pretreatment group. Mice were pretreated with HSYA 24 h before SAP induction, pancreatic and lung tissues were isolated for histopathological examination at 72 h after modeling, and bronchoalveolar lavage fluid (BALF) was collected for biochemical analysis. Results:Compared with the sham-operated group, serum amylase activity, lung injury pathological score and BALF protein concentration in the SAP group were significantly increased [(2120.44 ± 354.50) U/L vs. (226.72 ± 20.84) U/L; (6.91 ± 0.28) vs. (0.53±0.18); (2563.25±348.22) μg/mL vs. (345.62±56.35) μg/mL, all P<0.05]. Inflammatory factors tumor necrosis factor (TNF)-α and interleukin (IL)-6 levels and myeloperoxidase (MPO) activity were increased [(120.5±14.25) pg/mL vs. (31.5±4.82) pg/mL; (214.72±10.62) pg/mL vs. (39.26±5.66) pg/mL; (4.52±0.34) U/mg vs. (1.03±0.17) U/mg]. Compared with the SAP group, HSYA pretreatment significantly attenuated SAP-related pancreatic and lung tissue damage and the activities of the inflammatory factors TNF-α, IL-6 and MPO in BALF. In addition, HSYA promoted the expression of the antioxidant protein heme oxygenase-1 and blocked the activation of the NF-κB signaling pathway. Conclusions:HSYA exerts anti-inflammatory and antioxidant activities to inhibit SAP-related lung injury, which indicated that HSYA may be a potential therapeutic drug for SAP-induced lung injury.

Heterogeneity Analysis of Moderately Severe Acute Pancreatitis Based on the Revised Atlanta Classification / 胃肠病学

Background: Recent studies showed that the clinical outcome of moderately severe acute pancreatitis (MSAP) are different among different subgroups. Aims: To further subdivide MSAP, and explore the heterogeneity of MSAP subgroups. Methods: A retrospective analysis was performed on patients with acute pancreatitis (AP) from January 2016 to December 2020 at Northern Jiangsu People’s Hospital, including 538 patients with mild acute pancreatitis (MAP) and 461 patients with MSAP. MSAP patients were divided into four groups according to local complication and transient organ failure (TOF), including single acute peripancreatic fluid collection (APFC) without TOF group (group A), multiple APFC without TOF group (group B), other local complication without TOF group (group C) and TOF group (group D). The baseline data and the severity of AP among the four subgroups were compared. Meanwhile, the severity of disease between group A and MAP patients was also compared. Logistic regression analysis was used to evaluate the risk factors of MSAP. Results: Patients in group D were older than those in group A (P<0.05). There were statistically significant differences in different scoring systems among the four subgroups (P<0.05). The proportions of APACHE Ⅱ≥8, Glasgow≥3 and BISAP≥3 in group D were significantly higher than those in the other three groups (P<0.05). There were significant differences in levels of Ca

Bone marrow-derived mesenchymal stem cells ameliorate severe acute pancreatitis-induced lung injury in rats via suppression of ferroptosis / 中国临床药理学与治疗学

AIM: To evaluate the effect of bone marrow-derived mesenchymal stem cells (BMSCs) on ferroptosis in lung injury caused by severe acute pancreatitis (SAP). METHODS: BMSCs were obtained from male SD rats (3 weeks of age). 30 male SD rats (6 weeks of age) were randomly divided into 5 groups: Sham group, SAP group, SAP+PBS group, SAP+BMSCs group, and SAP+BMSCs+ML385 group, with 6 rats in each group. SAP model induced by sodium taurocholate (NaT) was established. Rats in the SAP+MSCs+ML385 group were intraperitoneally injected with ML385 (5 mg/kg) 2h before SAP induction. For PBS control and BMSCs treatment groups, PBS and BMSCs were respectively injected into rats via the tail vein 6 h after creation of the SAP model. All rats were sacrificed 3 days after SAP induction, and pancreas and lung tissue and serum samples were collected. Pancreatic and pulmonary injury was assessed using H&E staining. Serum levels of amylase and lipase and inflammatory factors, as well as tissue levels of iron, malondialdehyde (MDA), glutathione (GSH) were evaluated. The expressions of ferroptosis-associated proteins, including iron responsive element binding protein 2 (IREB2), ferritin heavy chain 1 (FTH1), acyl-CoA synthetase long-chain family member 4 (ACSL4), glutathione peroxidase 4 (GPX4), and solute carrier family 7 member 11 (SLC7A11), as well as the expressions of PI3K/AKT/Nrf2 pathway-related proteins were assessed. RESULTS: The serum levels of amylase, lipase and proinflammatory factors, as well as pathological scores were significantly increased after SAP induction (P<0.05). Changes above were effectively alleviated by BMSCs (P<0.05). Compared with SAP group, the iron and MDA contents were decreased, the GSH activity was increased, the expression of IREB2 and ACSL4 were downregulated and the expression of FTH1, GPX4 and SLC7A11 were upregulated in SAP+BMSCs group (P<0.05). Injection of ML385 partially offset the anti-lipid peroxidation effect of BMSCs (P<0.05). In addition, BMSCs upregulated the total protein levels of PI3K and p-AKT, and the nuclear protein level of Nrf2 in lung tissue (P<0.05). CONCLUSION: BMSCs can effectively reduce systemic inflammatory response and local tissue injury in SAP; BMSCs can inhibit iron deposition and lipid peroxidation in SAP-induced lung injury, and the anti-lipid peroxidation effect may be achieved via activating the PI3K/AKT/Nrf2 signaling pathway.

Study on the effects of Qingjie huagong decoction on the regulation of intestinal flora and intestinal mucosal barrier in severe acute pancreatitis model rats / 中国药房

OBJECTIVE To explore the the reg ulation of intestinal flora and effects of Qingjie huagong decoction on intestinal mucosal barrier in severe acute pancreatitis （SAP）mode rats . METHODS SAP rat model was induced by intraperitoneal injection of caerulein and lipopolysaccharide.The survival state of rats in each group were observed.The levels of serum amylase ，interleukin 10（IL-10），IL-18 and IL- 1β in serum were all detected. The pathological changes of pancreatic and small intestinal tissue were observed. The expressions of Occludin，ZO-1 and HMGB1 were detected in small intestinal tissue of rats. The structure and relative abundance of intestinal microflora in rats were detected by 16S rRNA high throughput sequencing. RESULTS After the intervention of Qingjie huagong decoction ，abdominal distension symptoms of SAP model rats were significantly relieved ，and their mental state recovered better ；the levels of serum amylase and IL- 18 in serum were decreased significantly （P＜0.05），while the level of IL- 10 was increased significantly （P＜0.05）. The necrotic area of pancreatic tissue and the infiltration of inflammatory cells were reduced ， the degree of intestinal epithelial cell structural disorder was alleviated ，and the shedding of intestinal mucosal epithelium was reduced.The protein expression of HMGB 1 in small intestinal tissue was decreased significantly （P＜0.05），and the protein expression of Occludin and ZO- 1 were increased significantly . Results of 16S rRNA high throughput sequencing showed that Qingjie huagong decoction could increased the relative abundance of probiotics such as Bacteroidea and Lactobacillus in rat intestine ，reduced the colonization of harmful bacteria such as Firmicutes. CONCLUSIONS Qingjie huagong decoction can improve the intestinal barrier by up-regulating the expression of Occludin and ZO- 1 in small intestinal tissue and down-regulating the protein expression of HMGB 1. It can also adjust the relative abundances of different flora to protect the intestinal tract.

Abdominal puncture drainage alleviates severe acute pancreatitis in rats by activating Nrf-2/HO-1 pathway and promoting autophagy / 南方医科大学学报

OBJECTIVE@#To assess the effect of early abdominal puncture drainage (APD) on autophagy and Nrf-2/HO-1 pathway in rats with severe acute pancreatitis (SAP) and explore the possibile mechanism.@*METHODS@#Thirty-two male SD rats were randomly divided into sham-operated (SO) group, SAP group with retrograde injection of 4% sodium taurocholate, APD group with insertion of a drainage tube into the lower right abdomen after SAP induction, and APD + ZnPP group with intraperitoneal injection of 30 mg/kg ZnPP 12 h before APD modeling. Blood samples were collected from the rats 12 h after modeling for analysis of amylase and lipase levels and serum inflammatory factors. The pathological changes of the pancreatic tissue were observed with HE staining. Oxidative stress in the pancreatic tissue was detected with colorimetry, and sub-organelle structure and autophagy in pancreatic acinar cells were observed by transmission electron microscopy. The expressions of autophagy-related proteins and Nrf-2/HO-1 pathway were detected using RT-PCR and Western blotting.@*RESULTS@#Compared with those in SAP group, the rats with APD treatment showed significantly alleviated pathologies in the pancreas, reduced serum levels of lipase, amylase and inflammatory factors, lowered levels of oxidative stress, and activated expressions of Nrf-2/HO-1 pathway in the pancreas. The ameliorating effect of ADP was significantly inhibited by ZnPP treatment before modeling. APD obviously reversed mitochondrial and endoplasmic reticulum damages and p62 accumulation induced by SAP.@*CONCLUSION@#APD treatment can suppress oxidative stress and repair impaired autophagy in rats with SAP by activating the Nrf-2/HO-1 pathway, thereby reducing the severity of SAP.

Role of CaMK II in pancreatic injury in mice with severe acute pancreatitis / 南方医科大学学报

OBJECTIVE@#To investigate the expression of Ca2+/calmodulin-dependent protein kinase II (CaMK Ⅱ) in pancreatic tissues of mice with severe acute pancreatitis (SAP) and explore the protective effect of KN93, a CaMK Ⅱ inhibitor, against pancreatic injury in SAP and the possible mechanism.@*METHODS@#Thirty-six healthy male C57 mice were randomly divided into sham operation group, SAP group, KN93 group and SAP + KN93 group (n=9). Serum and pancreatic tissue samples were collected 24 h after modeling. The pathological changes in the pancreatic tissues were observed using HE staining. Serum lipase and amylase activities and the levels of inflammatory factors were detected using ELISA. Western blotting was used to detect the expressions of CaMK Ⅱ, p-CaMK Ⅱ, p-NF-κB, MAPK and p-MAPK in mouse pancreas.@*RESULTS@#Compared with those in sham operation group, the expressions of p-CaMK Ⅱ, p-NF-κB and p-MAPK were significantly increased in SAP group (P < 0.05). KN93 treatment obviously alleviated pathological injuries of the pancreas in SAP mice, and significantly lowered serum levels of lipase, amylase and inflammatory factors (TNF-α and IL-6) and phosphorylation levels of NF-κB, ERK and MAPK proteins (P < 0.05).@*CONCLUSION@#The activity of CaMK Ⅱ is significantly increased in the pancreatic tissue of SAP mice. KN93 can alleviate pancreatic injury and inflammation in SAP mice possibly through the ERK/MAPK signaling pathway.

Clinical characteristics and prognostic analysis of children with acute pancreatitis in the pediatric intensive care unit / 中国小儿急救医学

Objective:To investigate the clinical characteristics and prognosis of children with acute pancreatitis(AP)admitted to the pediatric intensive care unit(PICU).Methods:The etiology, clinical data, imaging features, complications, and outcomes of children with AP admitted to PICU at Shanghai Children′s Hospital from July 2016 to June 2021 were retrospectively analyzed.Results:Totally, 47 patients with AP including 24 males and 23 females were enrolled.The mean age was 84(48, 144)months.Four patients with mild AP, 5 patients with moderately severe AP(MSAP)and 38 cases with severe AP(SAP)were diagnosed.The main etiology was drug-related pancreatitis in 23 cases(48.9%). The organ dysfunction mainly included shock in 28 cases(59.6%), acute respiratory failure in 21 cases(44.7%), gastrointestinal disorders in 30 cases(63.8%), and coagulopathy in 29 cases(61.7%). The complications included capillary leakage syndrome in 18 cases(38.3%)and hyperglycemia(>8 mmol/L)in 24 cases(51.1%). Serum amylase and lipase levels were increased in 47 cases(100%). There were significant differences in blood lactate[3.0(2.1, 4.5)mmol/L vs.1.6(1.1, 3.1)mmol/L, P=0.013], and the use of vasoactive drugs[15.0(0, 75.0)vs.0(0, 8.8), P=0.035] between drug-induced pancreatitis and non-drug-induced pancreatitis.All the patients′conditions were improved after treatment and transferred out of PICU. Conclusion:The etiology of acute pancreatitis in children is mainly drug-related, and the main organ dysfunction includes shock, acute respiratory failure, gastrointestinal dysfunction and coagulation dysfunction.The prognosis of childhood pancreatitis is good.

The value of serum levels of Apo B/A1, MAP1-LC3 and ICAM-1 in early assessment of acute pancreatitis / 中华急诊医学杂志

Objective:To investigate the early evaluation potential of serum levels of apolipoprotein B/apolipoprotein A1 (Apo B/A1), microtubule-associated protein 1-light chain 3 (MAP1-LC3) and intercellular adhesion molecule-1 (ICAM-1) in acute pancreatitis (AP) patients.Methods:A total of 413 AP patients who were treated at the Second Affiliated Hospital of Anhui Medical University between January 2019 and August 2020 were enrolled. Serum samples were collected from AP patients within 24 h of admission. Patients were divided into the non-severe acute pancreatitis (Non-SAP, n=315) and severe acute pancreatitis (SAP, n=98) groups according to the severity of the disease. Sixty healthy controls were recruited. The differences of serum Apo B/A1, MAP1-LC3 and ICAM-1 among the three groups were compared by one-way analysis of variance, and the correlation between Apo B/A1, MAP1-LC3 and ICAM-1 and the severity of AP was analyzed by Pearson correlation analysis. Sensitivity and specificity in assessing AP severity were predicted by receiver operating characteristic curve (ROC). Results:The early levels of Apo B/A1, MAP1-LC3 and ICAM-1 were all significantly higher for AP patients than for healthy controls ( P<0.05), and the levels of Apo B/A1, MAP1-LC3 and ICAM-1 in SAP patients were significantly higher than those in non-SAP patients[Apo B/A1: 2.21±1.40 vs. (0.96±0.34); MAP1-LC3: 0.92±0.29 vs. (0.48±0.24) ng/mL and ICAM-1: (235.57±54.50 ) vs. (120.28±61.69)ng/mL; P<0.05]. Pearson correlation analysis showed that levels of Apo B/A1, MAP1-LC3 and ICAM-1 were positively correlated with the first Ranson score after admission ( P<0.05), and ICAM-1 showed the highest degree of correlation with AP severity ( r=0.519). Areas under the receiver operating characteristic curve (AUROC) were 0.769 for Apo B/A1, 0.811 for MAP1-LC3, 0.828 for ICAM-1, and 0.938 for combined detection. Conclusions:Serum levels of Apo B/A1, MAP1-LC3 and ICAM-1 within 24 h after admission are significantly correlated with the severity of AP, which has clinical significance for early prediction of the severity of AP.