Chronic pancreatitis (CP) has a negative impact on quality of life (QoL). Because CP is a chronic condition, multiple assessments of QoL are required to obtain a thorough understanding of its impact ...on patients. Such studies are currently lacking. This study aims to gain insight into the course and predictors of QoL in patients with CP using prospective longitudinal data from a large cohort of patients.
Post hoc analysis of consecutive patients with definite CP registered in a prospective database between 2011 and 2019 in the Netherlands. Patient and disease characteristics, nutritional status, pain severity, medication usage, pancreatic function, and pancreatic interventions were assessed from medical records and through standard follow-up questionnaires. The physical and mental component summary scales of the Short-Form 36 were used to assess physical and mental QoL at baseline and during follow-up. The course of both physical and mental QoL and their associated factors were longitudinally assessed by using generalized linear mixed models.
Overall, 1,165 patients with definite CP were included for this analysis. During 10-year follow-up, generalized linear mixed model analyses revealed improvements in both physical (41.6-45.2, P < 0.001) and mental (45.9-46.6, P = 0.047) QoL. Younger age, current alcohol consumption, employment, no need for dietetic consultation, no steatorrhea, lower Izbicki pain score, and pain coping mechanism were positively associated with physical QoL ( P < 0.05). For mental QoL, a positive correlation was found between employment, nonalcoholic CP, no need for dietetic consultation, no steatorrhea, lower Izbicki pain score, pain coping mechanism, and surgical treatment. No association was observed between disease duration and longitudinal QoL per patient.
This nationwide study provides insight into the dynamics of physical and mental QoL in patients with CP over time. Important and potentially influenceable factors to improve QoL are nutritional status, exocrine pancreatic function, employment status, and patients' coping strategy.
Acute pancreatitis is complicated by local and systemic complications in 20–30% of the patients. Accurate prediction of severity may be important for clinical decision making. Our aim is to identify ...and compare the accuracy of laboratory biomarkers that predict severity and complications in adult patients.
Medline, EMBASE, Web of Science and Cochrane Library (1993 to August 2020) were searched for studies with an unselected population of patients with acute pancreatitis, that contains accuracy data for ≥1 laboratory biomarker(s) and/or APACHE-II score for the prediction of a patient outcomes of interest during the first 48 h of admission. The primary outcome is moderate severe or severe acute pancreatitis (MSAP/SAP). Secondary outcomes are severe acute pancreatitis, pancreatic necrosis and organ failure. Risk of bias was assed using QUADAS-2. Biomarkers extracted from ≥3 unique sources, were analyzed using hierarchical summary receiver operating characteristic (HSROC) and bivariate model analysis.
In total, 181 studies were included in the qualitative analysis reporting on 29 biomarkers. For the primary outcome at admission, summary sensitivities and specificities were, respectively, 87% (95% CI 69–95%) and 88% (95% CI 80–93%) for IL-6 at a threshold of >50 pg/ml, 72% (95% CI 64–79%) and 76% (95% CI 67–84%) for an APACHE-II score of ≥8, and 53% (95% CI 35–71%) and 82% (95% CI 74–88%) for CRP >150 mg/l. HSROC curve analysis confirmed these results.
This study indicates superiority of IL-6 for the early prediction of MSAP/SAP and may be used for to guide clinical decision making.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Pancreatoduodenectomy may lead to new-onset diabetes mellitus, also known as type 3c diabetes, but the exact risk of this complication is unknown. The aim of this review was to assess the risk of ...new-onset diabetes mellitus after pancreatoduodenectomy.
A literature search was performed in PubMed, Embase (Ovid), and the Cochrane Library for English articles published from March 1993 until March 2017 (PROSPERO registry number: CRD42016039784). Studies reporting on the risk of new-onset diabetes mellitus after pancreatoduodenectomy were included. For meta-analysis, studies were pooled using the random-effects model. All studies were appraised according to the Newcastle-Ottawa Scale.
After screening 1,523 studies, 22 studies involving 1,121 patients were eligible. The mean weighted overall proportion of new-onset diabetes mellitus after pancreatoduodenectomy was 16% (95% confidence interval, 12%–20%). We found no significant difference in risk of new-onset diabetes mellitus when pancreatoduodenectomy was performed for nonmalignant disease after excluding patients with chronic pancreatitis (19% risk; 95% confidence interval, 7%–43%; 6 studies) or for malignant disease (22% risk; 95% confidence interval, 14%–32%; 11 studies), P = .71. Among all patients, 6% (95% confidence interval, 4%–10%) developed insulin-dependent new-onset diabetes mellitus.
This systematic review identified a clinically relevant risk of new-onset diabetes mellitus after pancreatoduodenectomy of which patients should be informed preoperatively.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background
Thoracoscopic splanchnicectomy (TS) is a minimally invasive intervention to relieve pain in patients with chronic pancreatitis (CP) with equivocal results. Preoperative opioid use seems to ...impair TS outcome but this has not been investigated in a systematic matter.
Methods
We searched PubMed, EMBASE, and The Cochrane Library for studies on the outcome of TS in CP patients. Studies with ≥5 patients and a follow-up of ≥12 months were included. Success was defined as the proportion of patients free of opioids or who had a reduction of ≥4 points on a pain scale. The effect of opioid use on the success rate of TS was analyzed by uni- and multivariate regression.
Results
Sixteen studies with 484 patients were included in our review. The mean (±SD) age of the patients was 44 ± 4.3 years and 66 % were male. Median follow-up period was 21 months (IQR 14–35). Median preoperative opioid use was 85 % (IQR 54–100 %). After TS, a median of 49 % (IQR 22–75 %) of patients were free of opioids at end of follow-up. The median success rate was 62 % (IQR 48–86 %). Mean success rate in studies in which ≤50 % of the patients used opioids preoperatively was 81 % (SD ± 21) compared to 60 % (SD ± 15) for other studies (
p
= 0.049). Higher age, male gender, and lower rates of preoperative opioid use were associated with a higher success rate (
p
= 0.003, 0.047, and 0.017, respectively). Multivariate regression, including age, gender, preoperative opioid use, and duration of follow-up, identified age and preoperative opioid use as independent predictors of success after TS (both
p
= 0.002).
Conclusion
Preoperative opioid use is associated with a worse outcome after TS in CP patients. To optimize outcome, use of TS may be considered at an earlier stage in the treatment of patients with CP before prolonged opioid therapy.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Abstract
Background and study aims
Pancreatoscopy-guided electrohydraulic lithotripsy (EHL) has proven to be an effective first-line therapy in symptomatic chronic pancreatitis (CP) patients with ...obstructing pancreatic duct (PD) stones 1. However, long-term outcomes of endoscopic EHL remain unknown. The aim of the present study was to evaluate the long-term treatment effects of EHL as first-line therapy and to compare with those obtained in a historical cohort of patients who underwent extracorporeal shockwave lithotripsy (ESWL) as primary treatment.
Patients and methods
An observational retrospective single-center long-term follow-up study was performed including 19 consecutive patients who previously underwent endoscopic EHL compared to 18 patients who underwent ESWL followed by endoscopic retrograde pancreatography (ERP). The primary endpoint was long-term treatment success after EHL or ESWL defined as no recurrence of symptomatic intraductal stones confirmed on imaging. Secondary endpoints for the EHL-population included long-term clinical success (i. e., a similar or lower Izbicki Pain Score or reduction in opiate usage as compared to 6-month follow-up), quality of life (QoL), pancreatic function and hospital re-admission rate.
Results
In the EHL group, 37 % of the patients developed recurrent symptomatic PD stones versus 61 % in the ESWL group after a median follow-up of 35.0 and 76.5 months. Of the patients with recurrence, 71 % versus 100 % underwent a reintervention. Median time to recurrence was 12.0 versus 13.0 months. Clinical success sustained in 58 % of the EHL patients. QoL was not significantly different compared with 6-month follow-up and baseline.
Conclusions
Also at long-term follow-up, endoscopic EHL as first-line treatment is moderately effective for symptomatic CP patients with treatment success rates that seems at least equally effective as ESWL.
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BFBNIB, FZAB, GIS, IJS, KILJ, NUK, OILJ, SBCE, SBMB, UL, UPUK
7.
Adhesiolysis-Related Morbidity in Abdominal Surgery ten Broek, Richard P G; Strik, Chema; Issa, Yama ...
Annals of surgery,
2013-July, 2013-Jul, 2013-07-00, 20130701, Volume:
258, Issue:
1
Journal Article
Peer reviewed
OBJECTIVE:To determine the incidence of bowel injury in operations requiring adhesiolysis and to assess the impact of adhesiolysis on the incidence of surgical complications, postoperative morbidity, ...and costs.
BACKGROUND:Morbidity of adhesiolysis during abdominal surgery seems an important health care problem, but the direct impact of adhesiolysis on inadvertent organ damage, morbidity, and costs is unknown.
METHODS:In a prospective cohort study, detailed data on adhesiolysis were gathered by direct observation during elective abdominal surgery. Comparison was made between surgical procedures with and without adhesiolysis on the incidence of inadvertent bowel defects. Secondary outcomes were the effect of adhesiolysis and bowel injury on surgical complications, other morbidity, and costs.
RESULTS:A total of 755 (out of 844) surgeries in 715 patients were included. Adhesiolysis was required in 475 (62.9%) of operations. Median adhesiolysis time was 20 minutes (range1–177). Fifty patients (10.5%) undergoing adhesiolysis inadvertently incurred bowel defect, compared with 0 (0%) without adhesiolysis (P < 0.001). In univariate and multivariate analyses, adhesiolysis was associated with an increase of sepsis incidence odds ratio (OR)5.12; 95% confidence interval (CI)1.06–24.71, intra-abdominal complications (OR3.46; 95% CI1.49–8.05) and wound infection (OR2.45; 95% CI1.01–5.94), longer hospital stay (2.06 ± 1.06 days), and higher hospital costs $18,579 (15,204–21,954) vs $14,063 (12,471–15,655). Mortality after adhesiolysis complicated by a bowel defect was 4 out of 50 (8%), compared with 7 out of 425 (1.6%) after uncomplicated adhesiolysis (OR5.19; 95% CI1.47–18.41).
CONCLUSIONS:Adhesiolysis and inadvertent bowel injury have a large negative effect on the convalescence after abdominal surgery. The awareness of adhesion-related morbidity during reoperation and the prevention of postsurgical adhesion deserve priority in research and clinical practice.
Objective To estimate the disease burden of the most important complications of postoperative abdominal adhesions: small bowel obstruction, difficulties at reoperation, infertility, and chronic pain. ...Design Systematic review and meta-analyses. Data sources Searches of PubMed, Embase, and Central, from January 1990 to December 2012, without restrictions to publication status or language. Study selection All types of studies reporting on the incidence of adhesion related complications were considered. Data extraction and analysis The primary outcome was the incidence of adhesive small bowel obstruction in patients with a history of abdominal surgery. Secondary outcomes were the incidence of small bowel obstruction by any cause, difference in operative time, enterotomy during adhesiolysis, and pregnancy rate after abdominal surgery. Subgroup and sensitivity analyses were done to study the robustness of the results. A random effects model was used to account for heterogeneity between studies. Results We identified 196 eligible papers. Heterogeneity was considerable for almost all meta-analyses. The origin of heterogeneity could not be explained by study design, study quality, publication date, anatomical site of operation, or operative technique. The incidence of small bowel obstruction by any cause after abdominal surgery was 9% (95% confidence interval 7% to 10%; I2=99%). the incidence of adhesive small bowel obstruction was 2% (2% to 3%; I2=93%); presence of adhesions was generally confirmed by emergent reoperation. In patients with a known cause of small bowel obstruction, adhesions were the single most common cause (56%, 49% to 64%; I2=96%). Operative time was prolonged by 15 minutes (95% confidence interval 9.3 to 21.1 minutes; I2=85%) in patients with previous surgery. Use of adhesiolysis resulted in a 6% (4% to 8%; I2=89%) incidence of iatrogenic bowel injury. The pregnancy rate after colorectal surgery in patients with inflammatory bowel disease was 50% (37% to 63%; I2=94%), which was significantly lower than the pregnancy rate in medically treated patients (82%, 70% to 94%; I2=97%). Conclusions This review provides detailed and systematically analysed knowledge of the disease burden of adhesions. Complications of postoperative adhesion formation are frequent, have a large negative effect on patients’ health, and increase workload in clinical practice. The quantitative effects should be interpreted with caution owing to large heterogeneity. Registration The review protocol was registered through PROSPERO (CRD42012003180).
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BFBNIB, CMK, NMLJ, NUK, PNG, SAZU, UL, UM, UPUK
Patients with a first episode of acute pancreatitis can develop recurrent or chronic pancreatitis (CP). However, little is known about the incidence or risk factors for these events.
We performed a ...cross-sectional study of 669 patients with a first episode of acute pancreatitis admitted to 15 Dutch hospitals from December 2003 through March 2007. We collected information on disease course, outpatient visits, and hospital readmissions, as well as results from imaging, laboratory, and histology studies. Standardized follow-up questionnaires were sent to all available patients to collect information on hospitalizations and interventions for pancreatic disease, abdominal pain, steatorrhea, diabetes mellitus, medications, and alcohol and tobacco use. Patients were followed up for a median time period of 57 months. Primary end points were recurrent pancreatitis and CP. Risk factors were evaluated using regression analysis. The cumulative risk was assessed using Kaplan-Meier analysis.
Recurrent pancreatitis developed in 117 patients (17%), and CP occurred in 51 patients (7.6%). Recurrent pancreatitis developed in 12% of patients with biliary disease, 24% of patients with alcoholic etiology, and 25% of patients with disease of idiopathic or other etiologies; CP occurred in 3%, 16%, and 10% of these patients, respectively. Etiology, smoking, and necrotizing pancreatitis were independent risk factors for recurrent pancreatitis and CP. Acute Physiology and Chronic Health Evaluation II scores at admission also were associated independently with recurrent pancreatitis. The cumulative risk for recurrent pancreatitis over 5 years was highest among smokers at 40% (compared with 13% for nonsmokers). For alcohol abusers and current smokers, the cumulative risks for CP were similar-approximately 18%. In contrast, the cumulative risk of CP increased to 30% in patients who smoked and abused alcohol.
Based on a retrospective analysis of patients admitted to Dutch hospitals, a first episode of acute pancreatitis leads to recurrent pancreatitis in 17% of patients, and almost 8% of patients progress to CP within 5 years. Progression was associated independently with alcoholic etiology, smoking, and a history of pancreatic necrosis. Smoking is the predominant risk factor for recurrent disease, whereas the combination of alcohol abuse and smoking produces the highest cumulative risk for chronic pancreatitis.
IMPORTANCE: For patients with painful chronic pancreatitis, surgical treatment is postponed until medical and endoscopic treatment have failed. Observational studies have suggested that earlier ...surgery could mitigate disease progression, providing better pain control and preserving pancreatic function. OBJECTIVE: To determine whether early surgery is more effective than the endoscopy-first approach in terms of clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS: The ESCAPE trial was an unblinded, multicenter, randomized clinical superiority trial involving 30 Dutch hospitals participating in the Dutch Pancreatitis Study Group. From April 2011 until September 2016, a total of 88 patients with chronic pancreatitis, a dilated main pancreatic duct, and who only recently started using prescribed opioids for severe pain (strong opioids for ≤2 months or weak opioids for ≤6 months) were included. The 18-month follow-up period ended in March 2018. INTERVENTIONS: There were 44 patients randomized to the early surgery group who underwent pancreatic drainage surgery within 6 weeks after randomization and 44 patients randomized to the endoscopy-first approach group who underwent medical treatment, endoscopy including lithotripsy if needed, and surgery if needed. MAIN OUTCOMES AND MEASURES: The primary outcome was pain, measured on the Izbicki pain score and integrated over 18 months (range, 0-100 increasing score indicates more pain severity). Secondary outcomes were pain relief at the end of follow-up; number of interventions, complications, hospital admissions; pancreatic function; quality of life (measured on the 36-Item Short Form Health Survey SF-36); and mortality. RESULTS: Among 88 patients who were randomized (mean age, 52 years; 21 (24%) women), 85 (97%) completed the trial. During 18 months of follow-up, patients in the early surgery group had a lower Izbicki pain score than patients in the group randomized to receive the endoscopy-first approach group (37 vs 49; between-group difference, −12 points 95% CI, −22 to −2; P = .02). Complete or partial pain relief at end of follow-up was achieved in 23 of 40 patients (58%) in the early surgery vs 16 of 41 (39%)in the endoscopy-first approach group (P = .10). The total number of interventions was lower in the early surgery group (median, 1 vs 3; P < .001). Treatment complications (27% vs 25%), mortality (0% vs 0%), hospital admissions, pancreatic function, and quality of life were not significantly different between early surgery and the endoscopy-first approach. CONCLUSIONS AND RELEVANCE: Among patients with chronic pancreatitis, early surgery compared with an endoscopy-first approach resulted in lower pain scores when integrated over 18 months. However, further research is needed to assess persistence of differences over time and to replicate the study findings. TRIAL REGISTRATION: ISRCTN Identifier: ISRCTN45877994
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