The microbiology of infected pancreatic necrosis.

BACKGROUND: Acute pancreatitis (AP) continues to cause significant morbidity and mortality, especially when it leads to infected pancreatic necrosis (IPN). Modern treatment of IPN frequently involves prolonged courses of antibiotics in combination with minimally invasive therapies. This study aimed to update the existing evidence base by identifying the pathogens causing IPN and therefore aid future selection of empirical antibiotics. METHODS: Clinical data, including microbiology results, of consecutive patients with IPN undergoing minimally invasive necrosectomy at our institution between January 2009 and July 2016 were retrospectively reviewed. RESULTS: The results of 40 patients (22 males and 18 females, median age 60 years) with IPN were reviewed. The etiology of AP was gallstones, alcohol, dyslipidemia and unknown in 31, 2, 2 and 5 patients, respectively. The most frequently identified microbes in microbiology cultures were Enterococcus faecalis and faecium (22.5% and 20.0%) and Escherichia coli (20.0%). In 19 cases the cultures grew multiple organisms. The antibiotics with the least resistance amongst the microbiota were teicoplanin (5.0%), linezolid (5.6%), ertapenem (6.5%), and meropenem (7.4%). CONCLUSION: The carbapenem antibiotics, ertapenem and meropenem provide good antimicrobial cover against the common, mainly enteral, microorganisms causing IPN. Culture and sensitivity results of acquired samples should be regularly reviewed to adjust prescribing and monitor for emergence of resistance.

Conservative treatment and percutaneous catheter drainage improve outcome of necrotizing pancreatitis.

BACKGROUND/AIMS: To investigate the clinical effects of the maximum conservative treatment algorithm with percutaneous catheter drainage (PCD) as the first choice for necrotizing pancreatitis (NP). METHODOLOGY: Retrospectively analyzed NP patients who had fine needle aspiration (FNA) for proven infection of necrosis which was considered an indication for surgery (n=22, group 1) compared to patients subjected to maximum conservative treatment with PCD in NP patients (n=30, group 2). RESULTS: On admission, most baseline data did not show any statistical difference between the two groups, In group 2, all patients were implemented maximum conservative treatment, 25 of 30 patients were cured by PCD (83.3%), open necrosectomy were needed for 3 patients (10.0%) and 2 dead during hospitalization (6.7%). Whereas, in group 1, surgical operation rate was 45.6% and hospital mortality 31.8%, both of the ratios differed significantly compared with group 2 (45.6% vs. 10%, P=0.004; 31.8% vs. 6.7%, P=0.046 respectively). Furthemore, Hospital stay were significantly higher in group 1 compared with group 2 (90±18.5 vs. 39±13.4; P=0.033). CONCLUSIONS: A conservative approach with PCD as the first choice to treatment NP might decrease the rate of surgical operation and mortality, and improve the outcome of NP.

[Concomitant use of intravenous ozone therapy and small doses of direct current in the integrated treatment of patient with sterile pancreatonecrosis].

AIM: To estimate effectiveness of concomitant use of direct current in a small doses and intravenous ozone therapy in the integrated treatment of patients with sterile pancreatonecrosis. PATIENTS AND METHODS: 89 (39 women and 50 men, average age 48,2 +/- 3,6 years) Patient medical records, received a treatment for sterile pancreatonecrosis in surgery departments of Aktobe oblast were analyzed. In the period of 1997-2013, diagnosis of sterile pancreatonecrosis and its complication was found out on the basis of historical study, physical examination, clinical laboratory findings, ultrasound investigation and computerized tomography. All patients passed through complex basic conservative therapy and main group received also intravenous ozone therapy and small doses (20-25mkA) of direct current. RESULTS: Usage of small doses of direct current and intravenous ozone therapy in the integrated treatment of patients with sterile pancreatonecrosis helped on more rapid general well-being mend of patients. CONCLUSIONS: registered drop of transition frequency of sterile pancreatonecrosis into infected forms in 3 times, reduction of patients period of stay at hospital in 1,6 times and mortality rates--in 1,3 times.

Severe necrotic and septic pancreatitis. Indications to endoscopic, surgical, and nutritional therapy.

Severe acute pancreatitis (SAP) management has changed over the last fifteen years, and from too aggressive behaviour, we moved to a cautious one. In every case, we can appreciate defect of extremist conceptual position. We reviewed our strategy on disease treatment, and we analyzed treatment of single cases. We collected 4 SAP cases from January 2009 to January 2010. All patients were septic, and we adopted the same approach for all of them, avoiding surgery without peritoneal infection. In all patients we placed jejumostomy and, after cleaning of septic site, we started immediate enteral nutrition (EN). Antibiotic therapy against Gram+, Gram- and antifugal drug had been started. No one died and all patients were back to an active life even if social costs are considerably high especially due to very long hospital stay.

[Hot issues on the treatment of severe acute pancreatitis by Integrated Traditional Chinese and Western Medicine].

Severe acute pancreatitis (SAP) is recognized as critical refractory disease. The case fatality rate of SAP is as high as 36%-50%. Although significant progress has been achieved on the treatment of severe acute pancreatitis (SAP) by Integrated Traditional Chinese Medicine (TCM) and Western Medicine (WM), there still exist some difficulties hindering the further improvement of therapeutic efficacy. The hot issues includes: unconfirmative curative effects and diverse treatment principles, complicated predictive scoring systems and inaccurate markers for the severity stratification, unproved new therapeutic tools and controversial methods waiting more high qualified evidence, unclarified mechanism of Integrated TCM and WM. In order to overcome the difficulties, we aim to launch the clinical pathway of Integrated TCM and WM, to strengthen the unity of multidisciplinary cooperation. We also need to keep the efforts on screening the markers for early evaluation and prediction of disease severity, improving the diagnosis and treatment, exploring the mechanism of Traditional Chinese Medicine in treating SAP with more high quality basic and clinical research. Based on these efforts, we could provide better treatments and prognosis for SAP patients.

The microbiology of secondary and postoperative pancreatic infections: implications for antimicrobial management.

HYPOTHESIS: We reviewed our experience with secondary pancreatic infections with a focus on preemptive intervention and the potential alteration of the recovered microbial flora. The pathogens associated with postoperative pancreatic infections were analyzed with respect to nonenteric organisms, if any, that were recovered. We hypothesized that our findings might alter the antimicrobial management of these patients. DESIGN: Retrospective review. SETTING: Hospitals affiliated with the University of Tennessee Health Science Center, Memphis. PATIENTS: Patients developing secondary and postoperative pancreatic infections following severe acute pancreatitis. METHODS: Factors examined relative to secondary pancreatitis included preoperative antibiotic use and antecedent extrapancreatic infections potentially implicated in seeding the pancreatic bed. Patients who had elective resection received 24 to 48 hours of antibiotic prophylaxis. RESULTS: Twenty-two patients required surgery for secondary infections following severe acute pancreatitis, with 29 pathogenic isolates being recovered. Of these 22 patients, 14 received vancomycin hydrochloride prior to surgical intervention. Of those 14 patients, 6 had isolates recovered at the time of surgery that were positive for Enterococcus faecalis and 5 of these isolates were vancomycin resistant. Eight of the 22 patients received antifungal prophylaxis with no fungi recovered from intraoperative culture. However, 2 of the 14 patients who did not receive empiric therapy had isolates that were positive for fungi. Five patients who required an urgent operation for sepsis had pathogenic isolates that were similar to those recovered from central lines. Postoperative infections occurred in 40 of 225 patients (17.8%) who had an elective pancreatic resection, with 72 pathogenic isolates being recovered. Of these 40 patients, 22 (55.0%) had polymicrobial infections. Of the 72 pathogenic isolates recovered from patients, 34 (47.2%) were gram-positive organisms, 15 (20.8%) were fungal organisms, and 17 (23.6%) were drug-resistant bacteria. CONCLUSIONS: Prolonged vancomycin use in patients with severe acute pancreatitis is associated with the acquisition of vancomycin-resistant enterococci. Empiric antifungal therapy may reduce the incidence of secondary fungal pancreatic infections. Systemic bloodstream infections at extrapancreatic sites can lead to seeding of pancreatic pseudocysts. Postoperative infections frequently include gram-positive, fungal, and drug-resistant organisms, and empiric therapy directed at these pathogens should be utilized until definitive culture results are obtained.

[Selenium supplementation in patients with severe acute pancreatitis]. / Suplementácia selénu u pacientov s t'azkou akútnou pankreatitídou.

UNLABELLED: Selenium supplementation improves antioxidant status in critically ill patients with severe acute pancreatitis. It depends on quantum of dosage and supplementation time. The aim of this analysis is point out on benefit of antioxidant therapy by supplementing selenium. METHODS: Patient with severe acute pancreatitis and developing septic shock was admitted on anesthesiology and intensive care department. Adjuvant supplementation therapy with selenium was started in continual infusion 750 mg/24 h during next six days. Activity of antioxidant enzyme glutathione peroxidase and others inflammatory markers were decrease. A case report presents the possibility to affect on systemic inflammatory response syndrome pathogenesis in initial phase. It has to improve therapeutic progress in patients with severe acute pancreatitis.

[Application of thermostream method in the surgical treatment of infectious pancreatic diseases].

Application of thermostream method secures a safe sterilization in infected pancreatic affection. It was confirmed by the results of 9 operations, performed on pigs with follow-up to 270 days. Thermal influence toward infected pancreatic tissue was delivered using hot air stream during 20 sec for 1 cm2 area in temperature 140 degrees C. Interstitial oedema is local after thermostream processing of pancreas, the reversible structural-functional changes were revealed in the organ tissues, localized aside from the influence zone. According to bacteriological investigations data obtained, microflora was absent. Successful clinical trial of thermostream method in patients with infected pancreatic affection in an acute necrotic pancreatitis permits to recommend its wide application in surgical practice.

[Nutritional support and efficient gastroduodenal endoscopy in the treatment of acute pancreatitis and different forms of pancreonecrosis].

Nutrition support and molecular-genetic markers of the immune system at patients with complicated forms of gastric pathology. In this study presented results of surgery clinic of and oncology faculty SGMU to improve treatment patients with acute pancreatitis, and various forms of pancreonecrozis, through a balanced Threpsology support and operational gastrointestinal endoscopy.

[Ultrasound-guided percutaneous tube drainage combined with directly-viewed debridement with cholangioscopy: a mini-invasive strategy for peripancreatic necrotizing infection].

OBJECTIVE: To establish "an integrative therapy" of drainage and debridement on peripancreatic necrotizing infection (PPNI) with minimally invasive technique, and to detect its clinical effects. METHODS: There were 17 patients who accepted ultrasound-guided percutaneous tube drainage combined with directly-viewed debridement with cholangioscopy from March 2006 to January 2008. Percutaneous puncture and catheter (6 - 8 F) drainage were adopted on the patients suffering from PPNI with B-us guidance, then the drainage sinus was expanded progressively from 8 F to 24 F in diameter with Cook fascia dilator by degrees, and the 22 F or 24 F tube was easily placed into the interior of PPNI instead of the prior catheter. So a better drainage effect was achieved. One week later, the necrotizing tissue of PPNI could be observed and debrided with choledochoscope under a directly-viewed way through the enlarged new sinus. Thus, with the continuous tube drainage and repeated debridement, the focus was absorbed and covered gradually. RESULTS: Seventeen cases accepted the mini-invasive therapy, 15 cases were saved finally with cure rate of 88.2%, and 2 cases conversion to laparotomy because of some technical reasons. The mean healing time was 73 days, and the mean hospitalization time was 57 days. Bleeding was occurred in 2 cases localized in sinus and the inside of PPNI, digestive tract fistula was detected in 2 cases, and these patients with the complications were cured under nonoperative management. All the patients were still alive with following-up, neither remains nor recurrence of the PPNI was found in our group. CONCLUSIONS: Ultrasound-guided percutaneous tube drainage combined with directly-viewed debridement with cholangioscopy, as a mini-invasive therapy, could complete the goal-directed therapy of PPNI, meanwhile, realize the modern surgery ideal of damage control.

Rompiendo paradigmas en la Pancreatitis Aguda Grave una nueva visión en el tratamiento de la enfermedad / Breaking paradigms in the acute severe pancreatitis: a new vision in the treatment of the disease

El tratamiento de la pancreatitis aguda grave esta cambiando muy rápido en los últimos tiempos por lo que la actualización constante de las últimas tendencias nos obliga a variar frecuentemente los protocolos de manejo de la enfermedad, ya que lo que hoy es una verdad mañana podría ser un error. En la unidad de pancreatitis aguda grave del Hospital Rebagliati creemos que existen cuatro paradigmas que pueden cambiar nuestra manera de tratar esta enfermedad. En la unidad creemos que la terapia con antibiótico profiláctico no es efectiva paradisminuir la incidencia de necrosis infectada ni la mortalidad en la pancreatitis aguda con necrosis, ya que los trabajos publicados durante los dos últimos años demuestran una clara tendencia a la inefectividad de esta terapia. En el protocolo de la unidad no existe ninguna indicación para intervenir quirúrgicamente a la necrosis estéril. Por lo que el tratamiento quirúrgico podría ser un factor que aumentela severidad del cuadro, produciendo mayores índices de mortalidad en los pacientes con necrosis pancreática estéril. La verdadera y única indicación absoluta de cirugía es la Punción por aguja fina (P.A.F.) positiva, descartando a la ôsepsis en ausencia de foco infeccioso extra pancreático como indicación quirúrgica y dejando a la presencia de gas en la tomografía como indicación relativa para realizar una cirugía. En la Unidad creemos que la necrosectomia pancreática se puede realizar en un solo acto siempre y cuando se pueda retardar el acto quirúrgico el mayor tiempo posible.

The treatment of the severe acute pancreatitis has changed too fast in the last years and the new tendencies and continuous updates are forcing us to constantly vary the disease management protocols taking into account that what is true for today may prove to be a mistake tomorrow. In the Severe Acute Pancreatitis Unit of Eduardo Rebagliati Martins Hospital we believe there are four paradigms that can change the way we treat the disease. In the Unit we believe that a prophylactic antibiotic therapy is not effective in diminishing the incidence of infected necrosis nor in decreasing the death rate among patients with acute pancreatitis with necrosis, since the works published in the last two years make evident the clear tendency to the inefficiency of this therapy. In the protocol of the Unit there is no indication for surgical intervention of sterile necrosis since the surgical treatment could become the factor increasing the severity of the case that would cause higher death rates among patients with sterile pancreatic necrosis. The only and true absolute indication for surgery is a positive fine needle punction whichdiscards ôsepsis in the absence of an extrapancreatic source of infection as surgical indication and allows the presence of gas in the tomography to be a relative indication for surgical intervention. In the Unit we consider that a pancreatic necrosectomy can beperformed in one surgery as long as this can be delayed as much as possible.

[Application of ozone therapy in complex treatment of patients with acute necrotizing pancreatitis].

Examination and treatment of 32 patients was done, in whom an acute necrotic pancreatitis was diagnosed. In 16 patients (the main group) ozonotherapy, according to scheme, elaborated in the clinic, was added to conventional treatment. The ozonotherapy application had permitted to reduce the rate of performance of "open" operative interventions. The cellular, humoral and local immunity improvement and biochemical indices normalization were noted. The stationary treatment duration was 21.4 days at average in the main group and 34.5 -- in a control one. The relaparotomy performance rate in the main group was lesser than in a control one.

Treatment outcome of selective digestive decontamination and enteral nutrition in patients with severe acute pancreatitis.

BACKGROUND/PURPOSE: Sepsis due to infected pancreatic necrosis is the most serious complication in the late phase of severe acute pancreatitis (SAP). Bacterial translocation from the gut is thought to be the main cause of pancreatic infection. The possibility has recently been reported that selective digestive decontamination (SDD) and enteral nutrition (EN) may alleviate the complications and reduce the mortality rate in patients with SAP. We analyzed the treatment outcome of SDD and EN in patients with SAP. METHODS: We divided 90 patients with SAP into three groups: SDD(-)EN(-),group A; SDD(+)EN(-), group B; and SDD(+)EN(+), group C. Clinical outcome was analyzed retrospectively. The effect of SDD was compared in groups A and B, and the effect of EN was compared in groups B and C. RESULTS: The background of patients was not significantly different between the groups. SDD reduced the incidence of organ dysfunction (from 70% to 59%) and the mortality rate (from 40% to 28%), but the differences were not significant. EN reduced the incidence of infected pancreatic necrosis (from 31% to 24%) and the frequency of surgery for pancreas (from 28% to 18%), and further reduced the mortality rate (from 28% for SDD to 16%), but the differences were not significant. The peripheral lymphocyte count was significantly increased in patients with EN. CONCLUSIONS: SDD and EN did not significantly affect the treatment outcome in SAP. However, the results in this study raise the possibility that SDD and EN may decrease the complications and reduce the mortality rate in SAP. The efficacy of SDD and EN for SAP should be evaluated in a randomized controlled trial.

Surgical management and complex treatment of infected pancreatic necrosis: 18-year experience at a single center.

Infected pancreatic necrosis (IPN), the most severe form of acute pancreatitis, is responsible for most cases of pancreatitis-related morbidity and mortality. Since 1986, 220 patients with IPN have been treated. The surgical treatment was performed on average 18.5 days (range, 8-25 days) after the onset of acute pancreatitis and consisted of wide-ranging necrosectomy, combined with widespread drainage and continuous lavage. In 108 of the 220 cases, some other surgical intervention (distal pancreatic resection, splenectomy, total pancreatectomy, cholecystectomy, colon resection, etc.) was also performed. Following surgery, the supportive therapy consisted of immunonutrition (glutamine and arginine supplementation) and modification of cytokine production with pentoxifylline and dexamethasone. Continuous lavage was applied for an average of 44.5 days (range, 21-95 days), with an average of 9.5 L (range, 5-20 L) of saline per day. The bacteriologic findings revealed mainly enteral bacteria, but Candida infection was also frequently detected (21%). Forty-eight patients (22%) had to undergo reoperation. The overall hospital mortality was 7.7% (17 patients died). In our experience, IPN responds well to adequate surgical treatment, continuous, longstanding widespread drainage and lavage, together with supportive therapy consisting of immunonutrition and modification of cytokine production, combined with adequate antibiotic and antifungal medication.

Total enteral nutrition as prophylactic therapy for pancreatic necrosis infection in severe acute pancreatitis.

OBJECTIVE: To evaluate the capacity of enteral nutrition, in comparison with the total parenteral nutrition (TPN) plus antibiotic therapy, for avoiding pancreatic necrosis infection in the severe acute pancreatitis. METHODS: In the period between October 1998 and September 2003, 87 patients met the inclusion criteria and took part in this research. Within the first week from their admission, 43 patients received TPN and 44 patients received total enteral nutrition (TEN). An adequate prophylactic antibiotic therapy was used in both groups. The severity of the manifestations was similar for both groups having a tomographic 'severity index' of 8 and an entry C-reactive protein of 208 and 203 mg/l, respectively. RESULTS: The group that received TPN suffered an organ failure in 79% of the cases, while the percentage showed by the group that received TEN was 31%; 88 and 25% of the patients in each group requiring a surgical intervention, respectively (p < 0.001). There was decreased presence of pancreatic necrosis infection in the group of patients that was supplied with TEN (20%) than in the group receiving TPN, where it reached 74% (p < 0.001). The death rate was significantly higher among the patients who received TPN, (35%), while for the patients who received TEN it was only 5% (p < 0.001). CONCLUSION: TEN could be used as a prophylactic therapy for infected pancreatic necrosis since it significantly diminished the necrosis infection as well as the mortality.

[Clinical study on the treatment of severe acute pancreatitis by integrated traditional Chinese medicine and Western medicine].

OBJECTIVE: To sum up clinical experiences and formulate a new treatment program for the effective managment of severe acute pancreatitis(SAP) by integrated TCM and western medicine. METHODS: The therapeutic regimens and end results of 1376 cases of SAP in three periods were reviewed and analyzed. Period I (1980-1990) was characterized by early surgical intervention supplemented with integrated traditional Chinese and western medical therapy, period II (1991-1993) by integrated traditional Chinese and western medical therapy supplemented with surgery for early complications, and period III (1994-2003) by integrated traditional Chinese and western medical therapy supplemented with surgery for local infectious complications at a late stage in the course of disease. RESULTS: With use of integrated traditional Chinese and western medical therapy in the treatment of SAP, the proportion of surgical operation and the case-fatality rate kept declining in the three consecutive periods, the proportions of operation being 77.59%, 54.54% and 19.38%, and the case-fatality rates being 40.52%, 17.17% and 10.77%, respectively. CONCLUSION: Integrated TCM and western medicine is effective for most SAP cases, and surgery is indicated mainly for late complications such as necrotizing infection. Early surgery should be handled with more circumspection and strictness in most of the patients with SAP.

[Extracorporeal hemocorrection in acute pancreatitis]. / Ekstrakorporal'naia gemokorrektsiia pri ostrom pankreatite.

An experience with using 340 operations of extracorporeal hemocorrection in complex intensive therapy of 160 patients with acute pancreatitis has been generalized. In 111 of these patients (69%) pancreatic necrosis complicated by the syndrome of multiple organ failure was diagnosed. Based on the mechanisms of medical efficiency the authors have developed differential indications for using different extracorporeal technologies depending on the clinico-laboratory profile of the endogenous intoxication, structure and degree of organic and systemic dysfunctions. The adoption of such technologies allowed lethality to be reduced from 37.5 to 27.6%.

[Clinical protocols for the treatment of severe acute pancreatitis].

OBJECTIVE: To set up principles for the treatment of severe acute pancreatitis (SAP). METHODS: The therapeutic principles and results of SAP in three periods were analyzed. Period I (1980 - 1990) was characterized by early surgical intervention supplemented with integrated traditional and western medical therapy, period II (1991 - 1993) by integrated traditional and western medical therapy supplemented with surgery for early complications, and period III (1994 - 1997) by integrated traditional and western medical therapy supplemented with surgery for local infectious complications only. RESULTS: Because of the improvement of intensive care, the operation rates kept declining in the three periods. They were 77.59%, 54.55% and 29.55% with a mortality rate of 40.52%, 17.17% and 11.36%, respectively. CONCLUSIONS: Integrated traditional and western medicine has been effective in most SAP patients, and surgery is indicated only for late complications such as necrotizing infection. Early surgery should be restricted.

[Complex treatment of infected necrotizing pancreatitis]. / Inficiálódott nekrotizáló pancreatitis komplex kezelése.

Pancreatic necrosis associated with septic conditions is the leading cause of mortality in acute pancreatitis. Since 1986, 155 patients with infected pancreatic necrosis have been treated. The mean APACHE II score was 18.5 (range 11-32). In all cases, the infected pancreatic necrosis was combined with retroperitoneal abscesses. The surgical treatment was performed on average 18.5 days (range 8-25 days) after the onset of acute pancreatitis. The operative management consisted of wide-ranging necrosectomy in the total affected area, combined with widespread lavage and suction drainage. In 69 of the 155 cases (45%), some other surgical intervention (distal pancreatic resection, splenectomy, cholecystectomy, sphincteroplasty or colon resection) was also performed. Following surgery supportive therapy was applied in all patients, which also consisted orf immunonutrition (glutamine and arginine supplementation) and modification of cytokine production by petoxyfillin and dexamethasone from 1992. TNF and IL-6 serum levels were measured by ELISA and in vitro stimulation of leukocytes were induced by E. coli LPS. Following surgery, continuous lavage and suction drainage were applied for an average of 41.5 days (range 21-90 days), with an average of 9.5 (range 5-20) litres of saline per day. The bacteriologic findings revealed mainly enteral bacteria, but Candida infection was also frequently detected. The incidence of fungal infection was 20%. Thirty-two patients (21%) had to undergo reoperation. The cytokine production capacity (TNF and IL-6) was shown to correlate with the prognosis. As a consequence of pentoxifyllin and dexamethasone therapy, the TNF production generally dropped to the normal level. The overall hospital mortality was 6.4% (10 patients died). In our experience, infected pancreatic necrosis responds well to aggressive surgical treatment, continuous, long-standing lavage and suction drainage, together with supportive therapy consisting of immunonutrition and modification of cytokine production, combined with adequate antibiotic and antifungal medication.