Introduction: The relationship between pancreatitis and dyslipidaemia is unclear and has never been studied in a South African context. Patients and methods: A prospective evaluation of all admissions with acute pancreatitis to a regional hospital general surgical service was performed to ascertain its relationship to dyslipidaemia. Aetiology was determined by history and ultrasound assessment. Disease severity was assessed using a modified Imrie score and an organ failure score. Body mass index was calculated. A lipid profile was obtained. Abnormal profiles were repeated. Secondary causes of dyslipidaemia were noted. A comparison of the demographic profile, aetiology, disease severity scores, complications and deaths were made in relationship to the lipid profiles. Results: From June 2001 to May 2005, there were 230 admissions, of whom 31% were women and 69% men. The median age was 38 years(range 13- 73). The pancreatitis was associated with alcohol in 146(63%), gallstones in 42(19%) and idiopathic in 27(12%). The amylase was significantly higher with a gallstone aetiology (p / Thesis (MMedSc)-University of KwaZulu-Natal, 2006.

Chirurgische Eingriffe werden bei 10% der Patienten mit Komplikationen der chronischen Pankreatitis erforderlich. Neben Ableitungsoperationen kommt bei fokaler Akzentuierung der Erkrankung die Resektion von Teilen der Bauchspeicheldrüse zum Einsatz. Entzündliche Tumoren des Korpus und des Schwanzbereichs werden durch linksseitige Resektion, wenn möglich Milz erhaltend, entfernt. Zu den klassischen Resektionsverfahren von Pankreaskopfprozessen gehören die Duodenopankreatektomie (DPE) nach Kausch- Whipple und die Pylorus erhaltende Kopfresektion (PPPD). Im eigenen Krankengut wurden von Oktober 1993 bis Mai 2001 373 Patienten mit chronischer Pankreatitis behandelt. 104 Patienten wurden reseziert (27,9%). Neben 13 Linksresektionen, davon 5 Milz erhaltend, wurden 91 DPE durchgeführt (54 Kausch-Whipple, 37 PPPD). Von den 91 Patienten, die einer DPE unterzogen wurden, hatten 25,2% der Patienten einen Diabetes mellitus. Konservativ unbeeinflussbare Schmerzen bestanden in 93% der Fälle, ein Verschlussikterus war bei einem Drittel der Patienten aufgetreten. Der Gewichtsverlust in dieser Gruppe betrug median 14 (3–30) kg. Nach der Operation traten bei 28 Patienten (30,8%) Komplikationen auf. Fünf Patienten aus dieser Gruppe mussten reoperiert werden, keiner verstarb im postoperativen Verlauf. Für die Langzeitergebnisse konnten in einem Beobachtungszeitraum von median 20 Monaten bisher 49 Patienten nachuntersucht werden. Vier Patienten (8,2%) waren nach einer medianen Überlebenszeit von 22 Monaten verstorben. Von den verbleibenden 45 Patienten nach DPE hatten 51,1% im Median 7 (1–27) kg an Gewicht zugenommen. Postoperativ ist ein De-novo-Diabetes in 5 Fällen (11,1%) aufgetreten. Dreimal (6,1%) war nach DPE kein Diabetes mehr nachweisbar, 61,5% der Patienten wurden wieder arbeitsfähig. Wenn auch die untersuchte Patientengruppe noch klein ist, Spätergebnisse bisher nur an einem Teil der Behandelten erhoben werden konnten und der Vergleich verschiedener Serien nicht zulässig ist, scheint die klassische DPE bei der Kopfpankreatitis nach wie vor ein vertretbares Operationsverfahren zu sein. / Classic Resection Procedures in Patients with Chronic Pancreatitis Surgery is needed in 10% of patients with chronic pancreatitis. In cases with focal inflammation of the pancreatic head or tail, bypass procedures or partial resections are performed. If possible, the left part of the pancreas is resected, with preservation of the spleen. Duodenopancreatectomy (DPE) according to Kausch-Whipple and the pylorus-preserving resection of the pancreatic head (PPPD) belong to the classic resections. Between October 1993 and May 2001, 373 patients with chronic pancreatitis were admitted to our department. Resection was necessary in 104 patients (27.9%). 13 left-sided resections, with splenic preservation in 5 cases, and 91 DPE were performed, 54 of them as Kausch- Whipple operations and 37 as PPPD. In the group of 91 DPE, 25.2% of the patients were diabetic and 93% suffered from conservatively uncontrollable pain. One third of the patients presented with obstructive jaundice and median weight loss of 14 (3–30) kg. Early postoperative complications were observed in 28 cases (30.8%); no patient died. Up to now longterm results could be achieved in 49 patients, with a median follow-up of 20 months. Four patients (8.2%) died after a median survival time of 22 months. 51.1% of the 45 survivors after DPE gained 7 (1–27) kg of weight. De novo diabetes occurred postoperatively in 5 patients (11.1%). In 3 patients (6.1%) diabetes disappeared postoperatively, 61.5% returned to work. Although this group is small, long-term results are still incomplete and the comparison of different series does not allow to draw any significant conclusions, the classic DPE for chronic pancreatitis still seems to lead to quite remarkable results. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Proefschrift Universiteit van Amsterdam. / Met samenvatting in het Nederlands.

Tez (Tıpta Uzmanlık) - Süleyman Demirel Üniversitesi, Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, 2007. / Bibliyografya var.

Treatment of severe acute pancreatitis is considered to be conservative. The only generally accepted indication for surgery in severe acute pancreatitis patients is an established infection of the necrotic tissue and persisting or progressing symptoms of multiorgan failure despite the maximal intensive treatment. For surgical treatment are also indicated patients with complications of severe acute pancreatitis (erosive hemorrhage, perforation of GIT etc.). In the proposed work, attention is drawn to those cases, where the general condition of the patient deteriorates combined with a progression of ACS and where a decompressive laparotomy can improve the prognosis of the disease. In our group of 214 patients with severe acute pancreatitis, who were treated over the last six years, 70 patients were indicated for surgery. Out of this count, in 17 cases the indication for decompressive laparotomy was a raise of intraabdominal pressure up to the values of ACS together with the symptoms of organ dysfunction, 6 patients died and 11 younger patients survived.

BACKGROUND: Acute pancreatitis (AP) is a sterile initiator of systemic inflammation that can trigger multiple organ dysfunction syndrome (MODS). In the acute phase of AP, the kynurenine pathway of tryptophan metabolism plays an important role in the genesis of AP-MODS in experimental animal models, but it is unknown whether the pathway is activated in human AP. Human data are required to support the rationale for kynurenine 3- monooxygenase (KMO) inhibition as a treatment for AP-MODS and reinforce the translational potential. Additionally, as respiratory dysfunction is frequent in severe AP, the role of lung ultrasonography in severity stratification deserves investigation. Furthermore, the effect of AP-MODS on long-term survival is unknown. OBJECTIVES: My objectives were to: 1) Define the temporal and quantitative relationship of kynurenine metabolites with the onset and severity of APMODS, 2) Investigate the value of lung ultrasonography in the early diagnosis of respiratory dysfunction in human AP-MODS, and 3) Examine whether early AP-MODS impacts on long-term survival. METHODS: 1) A prospective, observational, clinical experimental medicine study titled “Inflammation, Metabolism, and Organ Failure in Acute Pancreatitis” (IMOFAP) was performed. For 90 days, consecutive patients with a potential diagnosis of AP were recruited and venous blood was sampled at 0, 3, 6, 12, 24, 48, 72 and 168 hours post-recruitment. Kynurenine metabolite concentrations were measured by liquid chromatography–tandem mass spectrometry (LC-MS/MS) and analysed in the context of clinical data, disease severity indices, and cytokine profiles. 2) In a nested cohort within IMOFAP, 41 participants underwent lung ultrasonography to evaluate whether this imaging modality can detect respiratory dysfunction in AP. 3) Survival data for a prospectively maintained database of patients with AP was analysed after accounting for in-hospital deaths. RESULTS: 1) During the IMOFAP study, 79 patients were recruited with an elevated serum amylase, of which 57 patients met the diagnostic criteria for AP; 9 had severe disease. Temporal profiling revealed early tryptophan depletion and contemporaneous elevation of plasma concentrations of 3- hydroxykynurenine, which paralleled systemic inflammation and AP severity. 2) Lung ultrasonography findings correlated with respiratory dysfunction. 3) 694 patients were followed up for a median of 8.8 years. AP-MODS conferred a deleterious effect on overall survival which persisted after the exclusion of inhospital deaths (10.0 years, 95% C.I. = 9.4-10.6 years) compared to AP without MODS (11.6 years, 95% C.I. = 11.2-11.9 years; P = 0.001). This effect was independent of age. CONCLUSIONS: In the acute phase of AP, metabolic flux through KMO is elevated and proportionate to AP severity. Lung ultrasonography may be a useful technique for evaluating AP-MODS. AP-MODS is an independent predictor of long-term mortality. Together, this work reinforces the rationale for investigating early phase KMO inhibition as a therapeutic strategy in humans.

Chronic pancreatitis (CP) is characterised by chronic, frequent, disabling abdominal pain. It often leads to exocrine and endocrine insufficiency resulting in malabsorption and diabetes mellitus respectively. The incidence of CP is 5-10 per 100,000 population worldwide and is on the rise in UK. Alcohol (70%) is the commonest aetiologic cause, idiopathic (20%) and others (10%) being second and third respectively. There are various medical and surgical treatment options available depending on clinical characteristics and the stage of disease. In spite of wide spectrum of therapeutic options, pain control still remains a challenging problem to the clinicians. Surgical treatments for chronic pancreatitis, broadly classified into resectional and drainage procedures, may offer relief of symptoms. These surgeries are associated with severe morbidity and high mortality. In addition, our comprehensive review of surgery in chronic pancreatitis demonstrated lack of criteria for baseline assessment of patients with CP; resulting in lack of standardization, variation in indication and comparability in published literature on surgical treatment of chronic pancreatitis. These factors have collectively forced the medical fraternity to look for other non or minimally invasive options. Oxidative stress and deficiency of anti-oxidants have long been implicated in pathogenesis of CP. Our review of literature on oxidative stress and antioxidants has highlighted the shortcomings and inadequacies from the previously published reports. These reports were underpowered and not all included patients had chronic pancreatitis. This in turn led us to propose a well designed randomised, double blind, placebo controlled trial of antioxidant therapy in CP. Considering the loss of time and productivity, it is necessary to undertake Qol as an outcome measure in any intervention related to CP. Our study assessed the suitability and feasibility of validated quality of life indices in patients with painful chronic pancreatitis. After correction for disease duration, the outcome of contemporary quality of life assessments showed that patients with CP taking Antox had better scores than controls. Cytokines, a group of proteins and glycoproteins that act in regulation of immunity, inflammation and haematopoiesis are implicated in oxidative stress related pathogenesis of chronic pancreatitis. They are broadly classed as pro-inflammatory and anti-inflammatory. There have been few experimental studies suggesting that antioxidants ameliorate cytokine response in chronic pancreatitis. However our study has failed to demonstrate a significant effect on cytokine levels after six months of antioxidant therapy. Similarly, on the clinical front, a randomised, double blind placebo controlled study (referred to as ANTICIPATE TRIAL) has shown no benefit of antioxidant therapy in painful chronic pancreatitis, irrespective of age, gender, aetiology or operative intervention. So we are afraid to say that until we discover any novel treatment in management of intractable painful chronic pancreatitis, surgery and interventional endoscopy might be the only viable options.

Conselho Nacional de Desenvolvimento CientÃfico e TecnolÃgico / A pancreatite aguda (PA) Ã considerada uma situaÃÃo de emergÃncia abdominal, na forma grave da doenÃa os pacientes desenvolvem acentuada resposta inflamatÃria sistÃmica e SÃndrome de DisfunÃÃo de MÃltiplos ÃrgÃos (SDMO). Um terÃo das mortes relacionadas com PA acontecem antes da admissÃo hospitalar, e a maior parte dos casos estÃo relacionados com lesÃo pulmonar aguda (LPA) e sÃndrome do desconforto respiratÃrio agudo (SDRA). Objetivos: Avaliar as alteraÃÃes inflamatÃrias e funcionais do pulmÃo no curso da pancreatite aguda experimental induzida por ceruleÃna. MÃtodos: PA foi induzida em Ratos Wistar, machos pensando 100-150g, pela administraÃÃo de 4 doses de ceruleÃna (20Âg/kg) com intervalo de uma hora e os grupos controle receberam apenas soluÃÃo salina. ApÃs 24 horas, os animais foram sedados, analgesiados e traqueostomizados e anÃlise da funÃÃo pulmonar foi realizada atravÃs da espirometria, onde foram avaliados Fluxo, Volume Corrente (VC), FrequÃncia RespiratÃria (FR) e Volume Minuto (VM), e da mecÃnica pulmonar onde foram observados ElastÃncia DinÃmica (Edin), ComplacÃncia DinÃmica (Cdin), PressÃo de Pico, ResistÃncia (Res). Lavado bronco-alveolar (LBA) foi realizado para contagem total e diferencial de cÃlulas. Amostra de sangue arterial foi colhida para avaliaÃÃo dos parÃmetros gasomÃtricos. Em seguida os animais foram sacrificados e nÃveis sÃricos de amilase, lipase, EPO, TNF-α, GRO-KC, MIP-1, VEGF, IL-1β, IL-2, IL-6, IL-10, IL-12, IL-17, IL-18 e de malondialdeÃdo (MDA) foram medidos. Atividade de mieloperoxidase (MPO) e avaliaÃÃo histolÃgica de pÃncreas e pulmÃo foram determinadas. AlÃm disso, amostras de sangue venoso foram colhidas para avaliaÃÃo de translocaÃÃo bacteriana. Resultados: NÃveis sÃricos de amilase, lipase, citocinas, MDA e atividade de MPO pancreÃtica e pulmonar estavam aumentados nos animais com PA; houve danos ao tecido pancreÃtico e pulmonar, revelados na histologia, nos animais que receberam ceruleÃna, quando comparados ao grupo controle. O LBA dos animais tratados com ceruleÃna demonstrou maior quantidade de cÃlulas, sendo predominantemente macrÃfagos. Gasometria arterial nÃo apresentou diferenÃa significativa entre os grupos. Fluxo, VC e VM se mostraram diminuÃdos nos animais com PA; FR permaneceu inalterada. Edin e PressÃo de Pico estavam maiores e Cdin estava menor nos animais com PA e nÃo houve alteraÃÃes na Res. Estudo da bacteremia foi negativo em ambos grupos. ConclusÃo: CeruleÃna induz PA em ratos com elevaÃÃo dos nÃveis de amilase e lipase pancreÃtica, com alteraÃÃes histopatolÃgicas no pÃncreas e no pulmÃo dependente do infiltrado neutrofÃlico, radicais livres e citocinas inflamatÃrias. PA induz alteraÃÃes espiromÃtricas e na mecÃnica pulmonar que nÃo sÃo dependentes de processo infeccioso. / Acute pancreatitis (AP) is considered an emergency abdominal, the severe form of the disease patients develop intense systemic inflammatory response and Multiple Organ Dysfunction Syndrome (MODS). About one-third of all deaths from acute pancreatitis has been reported to occur prior to admission to hospital, and in most cases, is associated with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Objectives: To assess the inflammatory and functional lung alterations in the course of AP induced by cerulein. Methods: Male Wistar rats (100-150g) were treated four times with one hour interval, intraperitoneally with cerulein (20 μg / kg, suspended in saline) or saline. Twenty-four hours after the first injection of cerulein, the animals were anesthetized, tracheostomized and placed in a spirometer for small animals and with following parameters evaluated: Flow, Volume(VC), Respiratory Frequency(RF) and Minute Volume(MV), and lung mechanics were observed where Dynamic Elastance (Edyn), Dynamic Compliance (Cdyn), Peak Pressure, Resistance (Raw). Bronchoalveolar lavage (BAL) was performed to count and differential cell. Arterial blood sample was drawn for assessment of pulmonary gas exchange parameters. Then the animals were sacrificed and serum amylase, lipase, EPO, TNF-α, GRO-KC, MIP-1, VEGF, IL-1β, IL-2, IL-6, IL-10, IL-12, IL-17, IL-18 and malondialdehyde (MDA) were measured. Myeloperoxidase activity (MPO) and histological evaluation of pancreas and lung were determined. In addition, venous blood samples were collected for evaluation of bacterial translocation. Results: Serum levels of amylase, lipase, cytokines, MDA and MPO activity of pancreatic and lung were increased in animals with PA, there was damage to pancreatic tissue and lung histology revealed, in animals that received cerulein compared to the control group. There was an increase in the number of BAL cells, predominantly macrophages. Arterial blood gas analysis showed no significant difference between groups. Flow, and MV proved lower in animals with PA; FR remained unchanged. Edyn and pressure peak were larger and Cdyn was lower in animals with PA and no changes in Res. There was no translocation in any groups. Conclusion: Cerulein induced AP in rats with elevated serum amylase and pancreatic lipase, with histopathological changes in the pancreas and lung dependent neutrophilic infiltrate, free radicals and inflammatory cytokines. PA induces spirometric and lung mechanics alterations that are not dependent on bacterial translocation

Class of 2005 Abstract / Objectives: To develop a decision analytic model to compare the clinical and economic outcomes of enteral nutrition (EN) and total parenteral nutritional (TPN) support in acute pancreatitis patients. Methods: All randomized clinical trials comparing EN and TPN in acute pancreatitis patients published in the medical and pharmacy literature were identified. Six trials were identified by searching MEDLINE, Web of Science, Cochrane Controlled Trials Register, International Pharmaceutical Abstracts, HealthStar, Cumulative Index to Nursing & Allied Health Literature, and citation review of applicable literature. The costs used for the decision tree were from the perspective of a hospital. A literature based decision tree was formed based from these costs and the probabilities of events from the six identified clinical trials. The TreeAge Pro computer program (TreeAge Software, Inc.; Williamstown, MA) was used to conduct the cost effectiveness analysis. Therapeutic success was considered, for the purposes of the trial, as having no complications. Results: EN was associated with a lower risk of infections, a reduced length of hospital stay, and fewer surgical interventions. There was no statistical difference in the risk of mortality, adult respiratory distress syndrome or multiple organ failure between groups treated with EN or TPN. The results found that EN dominated TPN by being both less costly and more effective. The average costs for EN and TPN were $46,345 and $73,878, respectively. The success rates were 0.652 and 0.358 for EN and TPN, respectively. Conclusion: Enteral nutrition was the dominant route of administration for nutritional support, when compared to total parenteral nutrition both clinically and economically for acute pancreatitis patients.

The spectrum of acute pancreatitis (AP) affects between 4.9 and 73.4 patients out of 100,000 worldwide annually (Tenner, Baillie, DeWitt, & Vege, 2013). AP uses the Atlanta classification system to establish a diagnosis of mild, moderate, or severe. The American College of Gastroenterology (ACG) has established comprehensive clinical practice guidelines (CPG) for the management of AP, the most recent version published in 2013 (Tenner et al., 2013). There have been similar CPGs published internationally that integrate current evidence-based research into recommendations for practice. These guidelines along with the ACG's guidelines recommend initiating a diet for mild acute pancreatitis patients due to research findings of improved patient outcomes (i.e. reduced length of hospital stay, decreased rate of infections, and reduced mortality) (Horibe et al., 2015; Lariño-Noia et al., 2014). There is an international awareness of the need for increased CPG nutrition recommendation compliance in the practice setting as many studies have found providers prefer to keep patients nil per os (NPO) and do not adhere to CPGs (Andersson, Andrén-Sandberg, Nilsson, & Andersson, 2012; Greenberg et al., 2016; Sun et al., 2013). The purpose of this doctor of nursing practice (DNP) project is to assess providers' current nutrition therapy practice and knowledge of the ACG’s CPG nutrition recommendations for mild AP patients. The researcher conducted the assessment with a hospitalist practice at Banner University Medical Center in Phoenix, Arizona. The results of the project contribute to the current body of research on national adherence to CPGs for AP and act as a needs assessment for future projects where a nutrition protocol order set may be established. The investigation of nutrition therapy for AP patients seeks to improve and standardize the care this patient population receives while in the acute care setting.