Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study.

BACKGROUND & AIMS: In patients with severe, necrotizing pancreatitis, it is common to administer early, broad-spectrum antibiotics, often a carbapenem, in the hope of reducing the incidence of pancreatic and peripancreatic infections, although the benefits of doing so have not been proved. METHODS: A multicenter, prospective, double-blind, placebo-controlled randomized study set in 32 centers within North America and Europe. PARTICIPANTS: One hundred patients with clinically severe, confirmed necrotizing pancreatitis: 50 received meropenem and 50 received placebo. INTERVENTIONS: Meropenem (1 g intravenously every 8 hours) or placebo within 5 days of the onset of symptoms for 7 to 21 days. MAIN OUTCOME MEASURES: Primary endpoint: development of pancreatic or peripancreatic infection within 42 days following randomization. Other endpoints: time between onset of pancreatitis and the development of pancreatic or peripancreatic infection; all-cause mortality; requirement for surgical intervention; development of nonpancreatic infections within 42 days following randomization. RESULTS: Pancreatic or peripancreatic infections developed in 18% (9 of 50) of patients in the meropenem group compared with 12% (6 of 50) in the placebo group (P = 0.401). Overall mortality rate was 20% (10 of 50) in the meropenem group and 18% (9 of 50) in the placebo group (P = 0.799). Surgical intervention was required in 26% (13 of 50) and 20% (10 of 50) of the meropenem and placebo groups, respectively (P = 0.476). CONCLUSIONS: This study demonstrated no statistically significant difference between the treatment groups for pancreatic or peripancreatic infection, mortality, or requirement for surgical intervention, and did not support early prophylactic antimicrobial use in patients with severe acute necrotizing pancreatitis.

Radiofrequency ablation has a valuable therapeutic role in metastatic VIPoma.

BACKGROUND: Vasoactive intestinal peptide-secreting tumours (VIPomas) are rare islet cell tumours of the pancreas that can result in life-threatening biochemical abnormalities. The optimal intervention for metastatic VIPoma remains undecided. This case history documents the clinical role of radiofrequency (RF) ablation in the treatment of metastatic VIPoma. CASE HISTORY: A primary pancreatic VIPoma was diagnosed in a 61-year-old female in 1998 and a distal pancreatectomy and splenectomy were performed. She remained disease-free for 44 months when she presented as an emergency with watery diarrhoea, hypokalaemia, renal failure and an elevated serum VIP level. CT scanning showed a liver metastasis and open RF ablation was performed with complete resolution of symptoms and biochemistry within 48 h. Post-ablation imaging confirmed complete ablation of the metastasis. She remained disease-free until 22 months later when watery diarrhoea resumed and a new hepatic metastasis was seen on CT. Percutaneous RF ablation was performed and follow-up CT scan showed complete ablation of the metastasis. The patient remains disease- and symptom-free 10 months after the second RF ablation. CONCLUSION: This case illustrates that the pronounced clinical and biochemical upset caused by metastatic VIPoma can be resolved safely, quickly and repeatedly by RF ablation.

Prognostic indicators in acute pancreatitis.

Several approaches have been used in an attempt to predict the severity and prognosis of attacks of acute pancreatitis. The Ranson and Glasgow criteria include a variety of simple laboratory parameters that are measured on admission and again within 48 h. They are the most widely used indices in clinical practice. The Acute Physiological and Chronic Health Evaluation II system is more complicated, but can be applied to a wide variety of conditions, especially in intensive care settings. The usefulness of this system depends on the threshold score for defining severe pancreatitis; a score of eight appears to be the most appropriate. The finding of nonperfused areas in the pancreas at contrast-enhanced computed tomography is indicative of pancreatic necrosis and portends an unfavourable prognosis. Other clinical and laboratory indices have been proposed, but the most important predictive factor of early mortality seems to be the presence and persistence of a Marshall organ failure score of two or more. This is especially true if organ dysfunction persists beyond 36 h. Radiological findings do not always correlate well with the presence of organ dysfunction, and more investigations are required.

IAP Guidelines for the Surgical Management of Acute Pancreatitis.

During 2002 the International Association of Pancreatology developed evidenced-based guidelines on the surgical management of acute pancreatitis. There were 11 guidelines, 10 of which were recommendations grade B and one (the second) grade A. (1) Mild acute pancreatitis is not an indication for pancreatic surgery. (2) The use of prophylactic broad-spectrum antibiotics reduces infection rates in computed tomography-proven necrotizing pancreatitis but may not improve survival. (3) Fine-needle aspiration for bacteriology should be performed to differentiate between sterile and infected pancreatic necrosis in patients with sepsis syndrome. (4) Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention including surgery and radiological drainage. (5) Patients with sterile pancreatic necrosis (with negative fine-needle aspiration for bacteriology) should be managed conservatively and only undergo intervention in selected cases. (6) Early surgery within 14 days after onset of the disease is not recommended in patients with necrotizing pancreatitis unless there are specific indications. (7) Surgical and other forms of interventional management should favor an organ-preserving approach, which involves debridement or necrosectomy combined with a postoperative management concept that maximizes postoperative evacuation of retroperitoneal debris and exudate. (8) Cholecystectomy should be performed to avoid recurrence of gallstone-associated acute pancreatitis. (9) In mild gallstone-associated acute pancreatitis, cholecystectomy should be performed as soon as the patient has recovered and ideally during the same hospital admission. (10) In severe gallstone-associated acute pancreatitis, cholecystectomy should be delayed until there is sufficient resolution of the inflammatory response and clinical recovery. (11) Endoscopic sphincterotomy is an alternative to cholecystectomy in those who are not fit to undergo surgery in order to lower the risk of recurrence of gallstone-associated acute pancreatitis. There is however a theoretical risk of introducing infection into sterile pancreatic necrosis. These guidelines should now form the basis for audit studies in order to determine the quality of patient care delivery.

Enteral and parenteral nutrition in acute pancreatitis.

In the last 5 years naso-enteric feeding has increasingly been used in clinical practice in patients with severe acute pancreatitis. Randomized clinical studies in both mild and severe forms of the disease have demonstrated not only the feasibility but also the safety of this approach. The majority of patients have been fed by variously placed nasojejunal tubes with varied problems in maintaining both location and patency. Most have been surprised to find that it is possible to feed the patients in this way with the potential of improving gut barrier function and immune response, at reduced cost and greater safety than with parenteral nutrition. The current evidence points to nasojejunal feeding being preferable to parenteral feeding, but evidence has yet to be produced to prove beyond reasonable doubt that such feeding is an improvement on conservative management without feeding. Finally, the most recent development has indicated that fine-bore nasogastric feeding may well be a realistic alternative to nasojejunal feeding even in the more severe forms of this disease. A small percentage of patients may still need parenteral nutrition.