Pancreatitis - It’s all about the timingmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/... ·...
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Transcript of Pancreatitis - It’s all about the timingmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/... ·...
Faculty/Presenter Disclosure
• Faculty: Jan DE WAELE
• Relationships with commercial interests: – Grants/Research Support: Sr. Clinical Researcher Fund Scientific
Research
– Speakers Bureau/Honoraria*: Accelerate, Bayer Healthcare, Grifols, MSD
– Consulting Fees*: AtoxBio, Bayer Healthcare, Cubist, MSD, Pfizer
– Other: none
* Fees and honoraria paid to institution
Background
• Acute pancreatitis management has changed
• Better understanding of pathophysiology
• Many paradigms no longer valid
Less is more
Early
• Inflammation
• MODS
• Often fulminant
Late
• (Peri)pancreatic infection
• Severity of disease variable
Intra-abdominal hypertension
Intra-abdominal hypertension?
Disease
• Pancreatic edema
• Peripancreatic fluid collections
• Ascites
• Ileus
Therapy
• Resuscitation induced edema
• Pancreatic tissue
• Intra-abdominal
• Abdominal wall
Epidemiology
De Waele JJ et al., World J Surg 2009, 33: 1128-33.
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Pupelis, 2002 De Waele, 2005 Keskinen, 2007 Chen, 2008 Al-Bahrani, 2008
IAH ACS
Consequences of increased IAP
IAH
Systemic
Shock
AKI
Respiratory insufficiency
Local
Intestinal hypoperfusion
Pancreatic necrosis
Intestinal ischemia
Bacterial translocation
Pancreatic infection
Intra-abdominal hypertension
Prevention
• Fluid management
• Nasogastric decompression
Target for intervention
• Percutaneous drainage of ascites
• Surgical intervention when necessary
Percutaneous drainage
• Prospective study in
acute pancreatitis
• ‘Routine therapy’ vs.
PCD
• n=110
• Improved APACHE II
scores at day 2 and 5
• Improved mortality
Sun ZX, World J Gastroenterol 2006 12: 5068-
70.
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D1 D2 D3
IAP
1800mL
Surgical decompression
Decompressive midline
laparotomy
• Effective in reducing
IAP
• Open abdomen and
risk for infection
• No debridement!
• Leave the peritoneum
intact when possible
Antibiotics in pancreatitis
Timing of infection
Besselink MG et al., Br J Surg 2009, 96: 267-273.
Mechanisms of infection
Bacterial translocation from the gut
• Ileus
• Intra-abdominal hypertension, low abdominal perfusion pressure
Direct contamination, e.g. GI perforation
Hematogenous Reflux from the
duodenum
AB prophylaxis studies
First author n Treatment in intervention group
Blinded Setting
Sainio 1995 60 Cefuroxime No Single center
Pederzoli 1993 74 Imipenem No Single center
Delcenserie 1996 23 Ceftazidime, amikacin + metronidazole
No Single center
Nordback 2001 58 Imipenem No Single center
Isenmann 2004 114 Ciprofloxacin + metronidazole
Double blind Multicenter
Dellinger 2007 100 Meropenem Double blind Multicenter
Rokke 2007 73 Imipenem No Multicenter
Xue 2009 56 Imipenem No Single center
Yang 2009 54 Imipenem No Single center
Barreda 2009 58 Imipenem No Single center
Garcia Barrassa 2009 41 Ciprofloxacin Double blind Single center
Antibiotic prophylaxis meta analysis
Jiang K, World J Gastroenterol 2012 18: 279-84.
Study quality and treatment effect
RCTs of antibiotic prophylaxis
de Vries AC, Pancreatology 2007 7: 531-
538.
Probiotics in SAP?
Probiotics
Reduction of bacterial overgrowth
Restoration of GI barrier function
Modulation of the immune system
Reduction of infectious complications
GI surgery
Pancreatitis
Besselink, MG. Lancet 2008 9613:651-659
Probiotics in SAP: PROPATRIA trial
Besselink, MG. Lancet 2008 9613:651-
659
Bowel rest and nutrition
Nutritional support in severe AP
EN in SAP
Tolerance of EN may be problematic
Abdominal pain
Nausea and vomiting
Ileus
Compression of duodenum by inflamed pancreas
Nasogastric feeding often possible – nasojejunal
when failure
Nutritional support in severe AP
EN preferred over PN
Well tolerated
• Pain scores similar
• Caloric targets reached
• Nitrogen balance comparable
Lower complication rate
• Infections
• MODS
Lower mortality (in some
studies)
Lower cost
The Python study
Bakker, OJ. N Engl J Med 2014 21:1983-
1993
The Python study
Bakker, OJ. N Engl J Med 2014 21:1983-
1993
The Python study
Bakker, OJ. N Engl J Med 2014 21:1983-
1993
Nutritional support in pancreatitis summary
• EN better than PN – optimal timing unclear
• Avoid early PN
• NG feeding can be attempted
NJ in case of symptoms or extensive necrosis
• Think of intra-abdominal hypertension
• If PN is used, consider glutamine
• Potential benefit of special EN formulations
Surgery for infection
Conservative vs interventional management
van Santvoort, HC. Gastroenterology 2011 4:1254-1263
Conservative patients (62%)
• Most had peripancreatic or <30% pancreatic necrosis
• 1/6 had organ failure
• 3% documented infection
• Mortality 7%
Intervention patients (38%)
• 75% pancreatitis necrosis
• 73% organ failure
• 78% infected necrosis
• Mortality 27%
Timing of intervention and outcome
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0-14d 14-29d >29d
Mortality Complications
van Santvoort, HC. Gastroenterology 2011 4:1254-1263
Source control in pancreatitis
van Santvoort HC et al., N Engl J Med
2010, 362: 1491-502.
PANTER study results
Outcome
van Santvoort HC et al., N Engl J Med
2010, 362: 1491-502.
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Major complicationsor death
Mortality New onset MODS
Open
Step-up
Predicting the need for surgery
Hollemans, RA. Ann Surg 2015
Predicting the need for surgery
Hollemans, RA. Ann Surg 2015
In conclusion – at the bedside
• IAP monitoring – targeted therapy – surgery if
persistent
• No antibiotics without infection – no probiotics
• Enteral nutrition – early – nasogastric if
tolerated
• Step-up approach in case of infection – though
failure of percutaneous drainage may be
predicted
