Evidence-based treatment of acute pancreatitis: a look at established paradigms

Abstract

Background: The management of acute pancreatitis (AP) is still based on speculative and unproven paradigms in many centers. Therefore, we performed an evidence-based analysis to assess the best available treatment.

Methods: A comprehensive Medline and Cochrane Library search was performed evaluating the indication and timing of interventional and surgical approaches, and the value of aprotinin, lexipafant, gabexate mesylate, and octreotide treatment. Each study was ranked according to the evidence-based methodology of Sackett; whenever feasible, we performed new meta-analyses using the random-effects model. Recommendations were based on the available level of evidence (A=large randomized; B=small randomized; C=prospective trial).

Results: None of the evaluated medical treatments is recommended (level A). Patients with AP should receive early enteral nutrition (level B). While mild biliary AP is best treated by primary cholecystectomy (level B), patients with severe biliary AP require emergency endoscopic papillotomy followed by interval cholecystectomy (level A). Patients with necrotizing AP should receive imipenem or meropenem prophylaxis to decrease the risk of infected necrosis and mortality (level A). Sterile necrosis per se is not an indication for surgery (level C), and not all patients with infected necrosis require immediate surgery (level B). In general, early necrosectomy should be avoided (level B), and single necrosectomy with postoperative lavage should be preferred over "open-packing" because of fewer complications with comparable mortality rates (level C).

Conclusions: While providing new insights into key aspects of AP management, this evidence-based analysis highlights the need for further clinical trials, particularly regarding the indications for antibiotic prophylaxis and surgery.

FIGURE 1. Antibiotic prophylaxis for necrotizing pancreatitis. The 95% confidence intervals (95% CI) for the logarithm of the odd ratios for indication for surgery, infected necrosis, sepsis, fungal infections, and mortality are plotted (P values presented on the right side). Heterogeneity between studies was evaluated using the χ² based Q statistic, and the results are provided in the right column of this figure: □, Schwarz et al; ○, Pederzoli et al; +, Nordback et al; x, Sainio et al; ▵, Isenmann et al; ▪, meta-analysis [all]; •, meta-analysis [chinolone + metronidazole]; ▴, meta-analysis [imipenem].

FIGURE 2. Emergency ERC for acute AP. The 95% confidence intervals (95% CI) for the logarithm of the odd ratios for mortality and local complications of emergency ERC in patients with acute AP. Heterogeneity between studies was evaluated using the χ² based Q statistic, and the results are provided in the right column of this figure: ⋄, Fan et al; ○, Fölsch et al; ▵, Neoptolemos et al; ▪, meta-analysis.