Thoracic epidural analgesia: a new approach for the treatment of acute pancreatitis?

This review article analyzes, through a nonsystematic approach, the pathophysiology of acute pancreatitis (AP) with a focus on the effects of thoracic epidural analgesia (TEA) on the disease. The benefit-risk balance is also discussed. AP has an overall mortality of 1 %, increasing to 30 % in its severe form. The systemic inflammation induces a strong activation of the sympathetic system, with a decrease in the blood flow supply to the gastrointestinal system that can lead to the development of pancreatic necrosis. The current treatment for severe AP is symptomatic and tries to correct the systemic inflammatory response syndrome or the multiorgan dysfunction. Besides the removal of gallstones in biliary pancreatitis, no satisfactory causal treatment exists. TEA is widely used, mainly for its analgesic effect. TEA also induces a targeted sympathectomy in the anesthetized region, which results in splanchnic vasodilatation and an improvement in local microcirculation. Increasing evidence shows benefits of TEA in animal AP: improved splanchnic and pancreatic perfusion, improved pancreatic microcirculation, reduced liver damage, and significantly reduced mortality. Until now, only few clinical studies have been performed on the use of TEA during AP with few available data regarding the effect of TEA on the splanchnic perfusion. Increasing evidence suggests that TEA is a safe procedure and could appear as a new treatment approach for human AP, based on the significant benefits observed in animal studies and safety of use for human. Further clinical studies are required to confirm the clinical benefits observed in animal studies

The clinical value of adipokines in predicting the severity and outcome of acute pancreatitis

BACKGROUND: Recent data shows that patients with severe acute pancreatic might benefit from early intensive therapy, enteral nutrition and timely transfer to specialized centers. The early prophylactic use of antibiotics in AP remains controversial. The role and need for new markers in stratification of acute pancreatitis is also uncertain. This study aims to evaluate the prognostic usefulness of adipokines in prediction of the severity and outcome of acute pancreatitis (AP). METHODS: Prospective study was conducted in four clinical centers. The diagnosis and severity assessment of AP was established according to the revised 2012 Atlanta classification. Adipokines, IL-6 and CRP levels were measured at admission and on 3rd day of hospital stay and compared with the control group. The predictive accuracy of each marker was measured by area under the receiver operating curve. RESULTS: Forty healthy controls and 102 patients were enrolled in to the study. Twenty seven (26.5 %) patients had mild, 55 (53.9 %) - moderate and 20 (19.6 %) - severe AP. Only resistin (cut-off value 13.7 ng/ml) and IL-6 (cut-off value 473.4 pg/ml) were reliable early markers of SAP. IL-6 with cut-off value of 157.0 pg/ml was a predictor of necrosis. The peripancreatic necrosis volume of 112.5 ml was a marker of SAP and 433.0 ml cut-off value could be used to predict the need of interventions. CONCLUSIONS: The prognostic value of adipokines in AP is limited. Only admission resistin levels could serve as an early predictor for SAP. The Lithuanian Regional Ethics Committee approved the study protocol (permission No. L-12-02/1/2/3/4) and all the patients and the control group provided written informed consent

IAP/APA evidence-based guidelines for the management of acute pancreatitis.

There have been substantial improvements in the management of acute pancreatitis since the publication of the International Association of Pancreatology (IAP) treatment guidelines in 2002. A collaboration of the IAP and the American Pancreatic Association (APA) was undertaken to revise these guidelines using an evidence-based approach.Twelve multidisciplinary review groups performed systematic literature reviews to answer 38 predefined clinical questions. Recommendations were graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The review groups presented their recommendations during the 2012 joint IAP/APA meeting. At this one-day, interactive conference, relevant remarks were voiced and overall agreement on each recommendation was quantified using plenary voting.The 38 recommendations covered 12 topics related to the clinical management of acute pancreatitis: A) diagnosis of acute pancreatitis and etiology, B) prognostication/predicting severity, C) imaging, D) fluid therapy, E) intensive care management, F) preventing infectious complications, G) nutritional support, H) biliary tract management, I) indications for intervention in necrotizing pancreatitis, J) timing of intervention in necrotizing pancreatitis, K) intervention strategies in necrotizing pancreatitis, and L) timing of cholecystectomy. Using the GRADE system, 21 of the 38 (55%) recommendations, were rated as'strong' and plenary voting revealed'strong agreement' for 34 (89%) recommendations.The 2012 IAP/APA guidelines provide recommendations concerning key aspects of medical and surgical management of acute pancreatitis based on the currently available evidence. These recommendations should serve as a reference standard for current management and guide future clinical research on acute pancreatitis

International Association of Pancreatology revised guidelines on acute pancreatitis 2025

Introduction: The International Association of Pancreatology, alongside the American Pancreatic Association, the European Pancreatic Club, the Indian Pancreas Club, and the Japan Pancreas Society, decided to update its earlier guidelines for the management of acute pancreatitis (AP) given the remarkable advances in our understanding of AP and its management over the last decade. Methods: These organizations put together a group of international experts to address important issues related to the management of AP. Guideline Development Groups comprising international domain experts framed clinically relevant questions and conducted thorough literature searches and systematic reviews to address the questions. Questions were framed in the PICO (Participant, Intervention, Comparator, and Outcome) format where appropriate. The evidence from the literature was synthesized to develop evidence-based recommendations for each question. The quality of evidence and the strength of the recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). For some questions, we have provided Good Practice Statements if enough direct evidence was unavailable. Results: The guidelines pertain to 18 domains comprising 96 questions. The recommendations cover almost all aspects of managing AP, including pain control, fluid therapy, patient stabilization, nutritional support, conservative and interventional treatment for infected necrotizing pancreatitis, management of complications, discharge criteria, guidance on follow-up, and strategies for prevention of recurrence. Specific types of AP, such as those associated with pregnancy, trauma, and metabolic factors have been given special attention. Conclusion: The recommendations presented here should serve as an evidence-based resource for practicing physicians and caregivers to treat patients with AP more effectively. In addition, the guidelines identify areas for future research, mainly targeted therapies for controlling systemic inflammation and mitigating organ dysfunction