review of literature on clinical pancreatology - The Pancreapedia

In the late 19th century, exploratory laparotomy gained momentum both to make a diagnosis<strong>of</strong> acute pancreatitis and to drain pancreatic abscesses and, in some instances, debridenecrotic tissue. Proponents <strong>of</strong> early surgical intervention including Senn, Körte, andMoynihan, although during the same period, were no less authorities than Fitz and Mikulicz,advocated conservative management [003, 089].The fervor for early surgical intervention was reversed after Gerhard Katsch’s (1887-1961)report, that during World War I and, subsequently, thereafter, that the number <strong>of</strong> patients withacute pancreatitis declined, and he attributed this to the starvation prevalent around this time[003]. The introduction <strong>of</strong> the assay for amylase also led to the recognition <strong>of</strong> milder forms <strong>of</strong>the disease and the spontaneous recovery <strong>of</strong> many patients with acute pancreatitis.Conservative treatment became established after Paxton and Payne reported, in a series <strong>of</strong>more than 300 patients, a mortality rate <strong>of</strong> nearly 45 percent in patients treated surgicallycompared with 23 percent in those patients treated conservatively [090].Beginning in the 1950s, the tide again turned to operative management as a means to treatpatients with severe acute pancreatitis. Both in Europe and in the United States, pancreaticresection was routinely performed early in the course <strong>of</strong> patients with severe acutepancreatitis to remove necrotic material despite mortality rates <strong>of</strong> 60-70 percent after suchtreatment. Indeed, in 1963, George Watts, a surgeon in Birmingham, successfully treated apatient experiencing "fulminant pancreatitis" and in shock with a total pancreatectomy.Although this operation initially gained support and was widely used, the appalling mortalityrate soon became evident and gave way to more cautious approaches in the late 1980s[010].The most noteworthy achievements in the treatment <strong>of</strong> acute pancreatitis have been theadvancements in supportive care including nutritional support, intensive care, andmanagement <strong>of</strong> shock and organ failure. The introduction <strong>of</strong> total parenteral nutrition (TPN)by Dudrick et al [091] vastly improved the ability to sustain critically ill patients, and TPNrapidly became a standard approach in patients with severe acute pancreatitis. Morerecently, the focus has shifted to enteral nutrition because there is increasing evidence tosuggest that it is safer, easier, as effective, and less expensive compared with TPN [092].However, the issue <strong>of</strong> "resting the gland" is still to be resolved, and there continues to bedebate about the relative merits <strong>of</strong> nasojejunal versus nasogastric feeding and the use <strong>of</strong>elemental formulas to minimize stimulation <strong>of</strong> the pancreas [010].The history <strong>of</strong> pharmacological approaches to treat acute pancreatitis and its complications iscomposed <strong>of</strong> a litany <strong>of</strong> failed trials dating back to the 1920s starting with the use <strong>of</strong> enzymeinhibitors such as quinine. Other medications that have been studied include aprotinin, whichwas even marketed commercially but eventually shown to have no benefit [093]antifibrinolytics [094], anticholinergics including atropine, H 2 -receptor antagonists, protonpump inhibitors, somatostatin, and octreotide [010]. Of these, somatostatin and octreotidewere extensively studied, but controlled trials have indicated little or no benefit [095, 096].Protease inhibition has also been investigated, and although gabexate mesylate, anantiprotease drug, has shown some promise in decreasing complication rates, clinical use <strong>of</strong>this drug is limited [096].Gallstone pancreatitisThe report <strong>of</strong> Classen et al [097] on elective endoscopic papillotomy and removal <strong>of</strong> commonbile duct stones opened up new frontiers in the treatment <strong>of</strong> gallstone pancreatitis andprovided an alternative to surgery. Safrany and Cotton [098] popularized emergentendoscopic sphincterotomy and stone extraction to treat acute gallstone pancreatitis. The