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Background:Biliary pancreatitis (BP) is common in adults and children. Current standard of care is to perform a cholecystectomy (CCE) to decrease the recurrence risk of pancreatitis. Controversy exists as to the timing of surgery,...
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Background:Biliary pancreatitis (BP) is common in adults and children. Current standard of care is to perform a cholecystectomy (CCE) to decrease the recurrence risk of pancreatitis. Controversy exists as to the timing of surgery, early versus delayed surgical intervention. Adult literature suggests a greater benefit of early CCE. Comparatively, there is limited pediatric literature as to the optimal timing of a CCE in children. We report a retrospective case series of children with BP who underwent early versus late CCE.Methods:A retrospective chart review was performed of children with BP for a period of 45 months. Reviewed information included patient demographics, timing of CCE, and the occurrence of adverse events preceding or following surgical intervention. Early CCE was defined as surgery during the index admission; late CCE was defined as surgery during a subsequent admission.Results:Nineteen children and adolescents (17 girls) were identified to have had BP with a subsequent CCE. Cholecystectomy was performed early in 9 patients with no adverse events. Ten patients had delayed surgery with 4 occurrences of adverse clinical events (recurrence of pancreatitis or biliary colic abdominal pain) while awaiting their CCE.Conclusions:Adverse biliary-related events occur at a higher rate in children with mild BP who undergo a delayed CCE when compared to early CCE performance. Early CCE is safe to perform in children with mild BP.
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Objectives Recent studies have shown a decrease in gallstone-related complications if same-admission cholecystectomy (SAC) is performed in mild gallstone pancreatitis (GSP); however, SAC often is not performed in resource-limited ...
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Objectives Recent studies have shown a decrease in gallstone-related complications if same-admission cholecystectomy (SAC) is performed in mild gallstone pancreatitis (GSP); however, SAC often is not performed in resource-limited settings such as safety net hospitals. The aims of this study were to evaluate the rate of SAC and compare a composite endpoint of recurrent biliary events in patients undergoing SAC with patients in the delayed cholecystectomy (DC) group. Secondary aims included evaluating the rate of recurrent pancreatitis in patients in the DC group, identifying the predictors for DC and the reasons for not undergoing SAC. Methods We reviewed 310 patients admitted in the past 5 years with the diagnosis of acute pancreatitis. Eighty patients were admitted for gallstone pancreatitis; 75% were African American, 18% were white, and the average age was 44 years with a mean body mass index of 30. Forty patients did not receive cholecystectomy before discharge. The DC and SAC groups were similar in body mass index, ethnicity, severity of pancreatitis, and complications. Results The DC group was significantly more likely to be older and with higher comorbidity indexes compared with the SAC group. Bedside Index of Severity in Acute Pancreatitis scores and revised Atlanta classification definitions were used to define severe acute pancreatitis; 10% (4) of patients had organ failure at 48 hours, whereas 17.5% (7) had a Bedside Index of Severity in Acute Pancreatitis scores >= 3. A total of 14 recurrent biliary events occurred in the DC group (14 of 40), which was 35% compared with 2 of 40 (5%) in the SAC group (P 2 was the only significant predictor of DC. The most common reason for DC was no surgical consultation during the inpatient stay (22%). Conclusions Our findings support existing evidence that DC is associated with a significantly increased risk of recurrent biliary events and pancreatitis. Furthermore, we report a 56% adherence to the current guidelines for SAC and report that the most common reason for not undergoing SAC was the absence of surgical consultation. We conclude that ensuring SAC in eligible patients should be a priority for safety net hospitals because it may help decrease hospital costs in the long term, and active efforts should be made to identify patients who may be less likely to receive SAC.
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Acute pancreatitis (AP) is the most common indication for hospital admission and its incidence is rising. It has a variable prognosis, which is mainly dependent upon the development of persistent organ failure and infected necroti...
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Acute pancreatitis (AP) is the most common indication for hospital admission and its incidence is rising. It has a variable prognosis, which is mainly dependent upon the development of persistent organ failure and infected necrotizing pancreatitis. In the past few years, based on large-scale multicenter randomized trials, some novel insights regarding clinical management have emerged. In patients with infected pancreatic necrosis, a step-up approach of percutaneous catheter drainage followed by necrosectomy only when the patient does not improve, reduces new-onset organ failure and prevents the need for necrosectomy in about a third of patients. A randomized pilot study comparing surgical to endoscopic necrosectomy in patients with infected necrotizing pancreatitis showed a striking reduction of the pro-inflammatory response following endoscopic necrosectomy. These promising results have recently been tested in a large multicenter randomized trial whose results are eagerly awaited. Contrary to earlier data from uncontrolled studies, a large multicenter randomized trial comparing early (within 24 h) nasoenteric tube feeding compared with an oral diet after 72 h, did not show that early nasoenteric tube feeding was superior in reducing the rate of infection or death in patients with AP at high risk for complications. Although early ERCP does not have a role in the treatment of predicted mild pancreatitis, except in the case of concomitant cholangitis, it may ameliorate the disease course in patients with predicted severe pancreatitis. Currently, a large-scale randomized study is underway and results are expected in 2017. (C) 2016 S. Karger AG, Basel
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Context: Many patients with unresectable pancreatic and peripancreatic cancer require treatment for malignant biliary obstruction. Objectives: To conduct a meta-analysis of the English language literature (1985-2011) comparing imm...
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Context: Many patients with unresectable pancreatic and peripancreatic cancer require treatment for malignant biliary obstruction. Objectives: To conduct a meta-analysis of the English language literature (1985-2011) comparing immediate biliary stent placement and immediate surgical biliary bypass in patients with unresectable pancreatic and peripancreatic cancer and analyze associated hospital utilization patterns. Methods: After identifying five randomized controlled trials comparing immediate biliary stent placement and immediate surgical biliary bypass, we performed a meta-analysis for dichotomous outcomes, using a random effects model. We compared resource utilization in terms of the number of hospital days before death by reviewing high-quality literature. Results: Three hundred seventy-nine patients were identified. We found no statistically significant differences in success rates between the two treatments (risk ratio [RR] 0.99; 95% CI 0.93-1.05; P = 0.67). Major complications and mortality were not significantly higher after surgical bypass (RR 1.54; 95% CI 0.87-2.71; P = 0.14). Recurrent biliary obstruction was significantly less frequent after surgical bypass than after stent placement (RR 0.14; 95% CI 0.03-0.63; P < 0.01). Despite similar overall survival rates, longer survival was associated with more hospital days before death in stent patients than in surgical patients. Conclusion: Nearly all patients with unresectable pancreatic cancer benefit from some procedure to manage biliary obstruction. Patients with low surgical risk benefit more from surgery because the risk of recurrence and subsequent hospital utilization are lower than after stent placement.
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Mechanistic studies of acute pancreatitis require animal models because clinical material is generally not available during theearly phases of the disease. Here we describe a protocol to induce biliary pancreatitis by retrogradely...
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Mechanistic studies of acute pancreatitis require animal models because clinical material is generally not available during theearly phases of the disease. Here we describe a protocol to induce biliary pancreatitis by retrogradely infusing bile acids into thepancreatic duct of anesthetized mice. The resulting model replicates events believed to be responsible for the onset of clinicalbiliary (i.e., gallstone) pancreatitis and creates highly reproducible pancreatitis with a severity that depends on the concentrationof infused bile acid. Pancreatitis reaches its maximal level of severity within 24 h of induction, and it resolves over the subsequentweek. This protocol enables the investigator to use genetically modified strains of mice, and it requires only relatively simple andeasily learned techniques of small animal surgery. With practice and gentle technique, the surgery (from induction of anesthesia tocompletion of the infusion) can be completed within 25 min per animal.
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Purpose: The purpose of the present study was to evaluate the visibility and the image quality of the biliary and pancreatic duct system on magnetic resonance cholangiopancreatography (MRCP) images based on two breath-hold (BH) me...
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Purpose: The purpose of the present study was to evaluate the visibility and the image quality of the biliary and pancreatic duct system on magnetic resonance cholangiopancreatography (MRCP) images based on two breath-hold (BH) methods using array spatial sensitivity technique: a single-shot fast spin-echo (SS-FSE) sequence and a three-dimensional single slab fast spin-echo (3D-FSE) sequence. Materials and methods: In the present prospective comparative study, 47 patients (22 male and 25 female, mean age=50 years, age range=22-82 years) that were referred for MRCP during a 12-month period are included. All of them were referred with suspected pancreaticobiliary disease. All patients underwent MRCP with both a SS-FSE BH sequence and a 3D-FSE BH sequence. Qualitative evaluation regarding the depiction of three segments of the pancreaticobiliary tree and the frequency of artifacts was performed. Two radiologists graded each sequence of the obtained studies in a blinded fashion. Quantitative evaluation including calculation of relative signal intensity (rSI) and relative contrast (RC) ratios at seven segments of the pancreaticobiliary tree between fluid-filled ductal structures and organ parenchyma at the same ductal segments was performed. In order to evaluate the parameters' differences of the two sequences, either in qualitative or in quantitative analysis, the Wilcoxon paired signed-rank test was performed. Results: On quantitative evaluation, both rSI and RC ratios of all segments of the pancreaticobiliary tree at SS-FSE BH sequence were higher than those at 3D-FSE BH sequences. This finding was statistically significant (P< .01). On qualitative evaluation, the two radiologists found intrahepatic ducts and pancreatic ducts to be better visualized with SS-FSE BH than with 3D-FSE BH sequence. This finding was statistically significant (P< .02). One of them found extrahepatic ducts to be significantly better visualized with SS-FSE BH sequence. Moreover, the frequency of artifacts was lower in the SS-FSE sequence, a finding that was of statistical significance. Interobserver agreement analysis found at least substantial agreement (κ>0.60) between the two radiologists. Conclusion: The SS-FSE sequence is performed faster and significantly improves image quality; thus, it should be included into the routine MRCP sequence protocol at 3.0 T. Furthermore, we recommended SS-FSE BH MRCP examination to be applied to uncooperative patients or patients in emergency because of its short acquisition time (1 s).
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Background Gallstone pancreatitis (GSP) has evidence-based guidelines regarding management. Both the International Association of Pancreatology/American Pancreatology Association and American College of Gastroenterology recommend ...
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Background Gallstone pancreatitis (GSP) has evidence-based guidelines regarding management. Both the International Association of Pancreatology/American Pancreatology Association and American College of Gastroenterology recommend index admission cholecystectomy (IAC) in patients presenting with mild GSP. The aim of this study was to examine guideline adherence and GSP recurrence rate when IAC was not performed. A comparison between admitting specialty was also performed to examine the difference in compliance rates.
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Background:The aim of this study was to determine the most feasible and cost-effective time of cholecystectomy following gallstone pancreatitis in Chinese patients.Materials and Methods:A total of 233 patients who underwent cholec...
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Background:The aim of this study was to determine the most feasible and cost-effective time of cholecystectomy following gallstone pancreatitis in Chinese patients.Materials and Methods:A total of 233 patients who underwent cholecystectomy for biliary pancreatitis (January 2004 to July 2012) were categorized into one of 2 groups: group A patients underwent cholecystectomy during admission (n=123), and group B patients delayed cholecystectomy after discharge from admission (n=110).Results:The groups were comparable in demographics, comorbidities, and disease severity. In total, 100% of patients in group A had a cholecystectomy within 3 weeks after admission, and 60.9% of patients in group B experienced precholecystectomy gallstone-related events (including 15 cases of recurrent pancreatitis) after discharge. The median total length of hospital stay was greater for group B than for group A [12 d (range, 4 to 24 d) vs. 17 d (range, 9 to 39 d), respectively, P=0.000]. The average cost of management was greater in group B than group A [23,036.11 Yuan (range, 9073.53 to 85,132.33 Yuan) vs. 36,643.27 Yuan (range, 14,096.36 to 69,642.02 Yuan), respectively, P=0.000].Conclusion:In Chinese patients, cholecystectomy should be performed within 3 weeks after admission without delay, and is feasible and cost-effective.
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Background/objectives: Gallstones are the leading cause of acute pancreatitis in developed countries. National and international guidelines recommend that a cholecystectomy should be performed during the index hospitalization for ...
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Background/objectives: Gallstones are the leading cause of acute pancreatitis in developed countries. National and international guidelines recommend that a cholecystectomy should be performed during the index hospitalization for acute gallstone pancreatitis. We aimed to delineate the national trends for same-admission cholecystectomy and ERCP for acute gallstone pancreatitis over the last ten years.
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Trotz zunehmender Aufklärung der Pathophysiologie der akuten Pankreatitis ist eine pankreasspezifische Therapie, z. B. eine Hemmung der Proteasen, nicht erfolgreich. Wahrscheinlich greift dieser therapeutische Ansatz zu spät in ...
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Trotz zunehmender Aufklärung der Pathophysiologie der akuten Pankreatitis ist eine pankreasspezifische Therapie, z. B. eine Hemmung der Proteasen, nicht erfolgreich. Wahrscheinlich greift dieser therapeutische Ansatz zu spät in den pathophysiologischen Ablauf ein. Entscheidend ist die Beurteilung des Schweregrades der Erkrankung und ein interdisziplinäres therapeutisches Vorgehen: Schmerztherapie, enterale Ernährung via Ernährungssonde, Behandlung der extrapankreatischen Komplikationen wie Verbrauchskoagulopathie, Ateminsuffizienz und Nierenversagen. Eine Schlüsselstellung liegt in der Bilanzierung der ausgedehnten Flüssigkeitsverluste. Die prophylaktische Antibiotikaapplikation bei Nekrotisierung zur Verhinderung einer Infektion kann erwogen werden. Bei bereits infizierten Nekrosen besteht Operationsindikation. Bei biliärer Pankreatitis erfolgt bei Nachweis von Gallengangssteinen die endoskopische retrograde Cholangiopankreatographie mit Papillotomie und im Intervall die elektive Cholezystektomie.Despite our increasing knowledge in the pathophysiology of acute pancreatitis therapeutic strategies based on this knowledge, such as inhibition of proteases, are not convincing. It is most likely that these strategies are initiated to late after the onset of pancreatitis. It is of utmost importance to clarify the severity of the disease for planning interdisciplinary approaches: therapy of pain, enteral nutrition via a jejunal tube, as well as treatment of extrapancreatic complications, such as respiratory insufficiency, coagulopathy, and renal insufficiency. A key role plays the exact balance of potential high fluid losses. Prophylactic application of antibiotics such as imipenem in cases of necrotizing pancreatitis to prevent infection is widely used. Infected necroses are an indication for surgery. In biliary pancreatitis one has to remove impacted bile duct stones via ERCP and papillotomy followed by elective cholecystectomy.Schlüsselwörter Akute Pankreatits - Nekrotisierende Pankreatitis - Biliäre Pankreatitis - ERCP - KomplikationenKeywords Acute pancreatitis - Necrotizing pancreatitis - Biliary pancreatitis - ERCP - ComplicationsDie Literatur zu diesem Beitrag finden Sie auf den Seiten XX–XX im Beitrag Mössner J, Keim V: Therapie der chronischen Pankreatitis.
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