review of literature on clinical pancreatology - The Pancreapedia

An inherent difficulty in comparing outcomes across hospitals is the difference in baselineclinical severity <strong>of</strong> diseases. High-volume centers typically serve as referral hospitals and arelikely to treat a more severely ill patient population. As a result, high-volume centers thataccept outside hospital transfers may report worse overall outcomes compared with lowvolumecenters. The use <strong>of</strong> propensity scores to create a matched cohort <strong>of</strong> patients hasemerged as an important method for risk adjustment in outcomes research. A characteristicfeature <strong>of</strong> a propensity-matched cohort study is that patients are matched according toexposure, in contrast to a traditional case-control study wherein patients are matchedaccording to outcome. After risk adjustment, treatment in a high-volume center was thenassociated with reduced mortality, length <strong>of</strong> stay, and charges. There are several potentialexplanations for the impact <strong>of</strong> hospital volume on outcomes in acute pancreatitis. In the pastdecade, numerous developments have emerged in management <strong>of</strong> acute pancreatitis,including aggressive fluid resuscitation, enteral nutritional support, and use <strong>of</strong> innovativeendoscopic, radiologic, and operative techniques for specific complications. Themanagement <strong>of</strong> complicated cases <strong>of</strong> acute pancreatitis requires not only the availability <strong>of</strong>numerous specialty services (critical care, gastroenterology, surgery, and interventionalradiology), but also the experience to coordinate such multidisciplinary care. The task athand is to identify which practices contribute to the success <strong>of</strong> high-volume centers as wellas to determine which patients may benefit from treatment in a high-volume center. Theimpact <strong>of</strong> hospital volume on outcomes in acute pancreatitis requires further evaluationbefore policy decisions can be considered [171].CholecystectomyIt was explored whether admission volumes for cholecystectomy and pancreatitis wereassociated with receiving cholecystectomy after hospitalization for acute biliary pancreatitis(ABP). It was identified admissions for ABP in the Nationwide Inpatient Sample between1998 and 2003. It was used multivariate analysis to assess the association betweenlikelihood <strong>of</strong> cholecystectomy and hospital volumes <strong>of</strong> cholecystectomy, pancreatitis, andendoscopic retrograde cholangiopancreatography (ERCP). The overall rate <strong>of</strong>cholecystectomy for ABP was 50 percent. After adjustment for confounders, the likelihood <strong>of</strong>cholecystectomy increased with every quartile <strong>of</strong> cholecystectomy volume relative to thebottom quartile (adjusted odds ratios <strong>of</strong> 4.36, 7.92, and 12.51 for quartiles 2, 3, and 4,respectively). Pancreatitis volume was inversely correlated with likelihood <strong>of</strong> cholecystectomy(adjusted odds ratios <strong>of</strong> 0.72, 0.62, and 0.48 for quartiles 2, 3, and 4, respectively, vs bottomquartile). Admissions to hospitals in the top quartile for ERCP volume (>35 ERCPs/year) had15 percent lower odds <strong>of</strong> cholecystectomy than the lowest quartile. Patients from rural areasand with lower income were disproportionately admitted to hospitals with lowercholecystectomy volumes. It was concluded US hospitals are not achieving targets forcholecystectomy after acute biliary pancreatitis as set by national and internationalguidelines. Centers with smaller cholecystectomy volumes are the least adherent torecommendations for cholecystectomy possibly because <strong>of</strong> hospital-level resource limitations[172].Diagnostics in acute pancreatitisSymptomsIt was reported the coexistence <strong>of</strong> Cullen's and Grey Turner's signs in acute pancreatitis[173].