review of literature on clinical pancreatology - The Pancreapedia

was 13 percent (n=2) and at lot B 37 percent (n=7). The tardive mortality by sepsis was nullat subjects with lavage and was 16 percent (n=3) at subjects without lavage. The precociousmortality was 13 percent (n=2) in the A lot and 21 percent (n=4) in the lot B. The averagehospitalization was 26 days in subjects with peritoneal lavage and 36 days in those treatedconservatively, the difference is statistically significant. The method has proved notgenerating <strong>of</strong> morbidity and supplementary mortality. Study <strong>of</strong> the variation <strong>of</strong> serum andperitoneal concentrations <strong>of</strong> interleukin 6 shows the modulator effect <strong>of</strong> the peritoneal lavageearly and prolonged <strong>of</strong> the inflammatory response and <strong>of</strong>fers an argument <strong>of</strong> the inefficiency<strong>of</strong> short peritoneal lavage [226].ProbioticsA cohort study <strong>of</strong> 731 patients with a primary episode <strong>of</strong> acute pancreatitis in 2004-2007,including 296 patients involved in a randomized controlled trial to investigate the value <strong>of</strong>probiotic treatment in severe pancreatitis, was evaluated regarding time <strong>of</strong> onset <strong>of</strong>bacteraemia, pneumonia, infected pancreatic necrosis, persistent organ failure and deathwere recorded. The initial infection in 173 patients was diagnosed a median <strong>of</strong> 8 (interquartilerange 3-20) days after admission (infected necrosis, median day 26;bacteraemia/pneumonia, median day 7). Eighty percent <strong>of</strong> 61 patients who died had aninfection. In 154 patients with pancreatic parenchymal necrosis, bacteraemia wassignificantly associated with increased risk <strong>of</strong> infected necrosis (65 vs 38 %). In 98 patientswith infected necrosis, bacteraemia was associated with higher mortality (40 vs 16 %). Inmultivariable analysis, persistent organ failure (odds ratio 18.0), bacteraemia (odds ratio 3.4)and age (odds ratio 1.1) were associated with death. It was concluded that infections occurearly in acute pancreatitis, and have a significant impact on mortality, especially bacteraemia[227].To determine the relation between intestinal barrier dysfunction, bacterial translocation, andclinical outcome in patients with predicted severe acute pancreatitis and the influence <strong>of</strong>probiotics on these processes a randomized, placebo-controlled, multicenter trial on probioticprophylaxis (Ecologic 641) in patients with predicted severe acute pancreatitis wasperformed (PROPATRIA). Excretion <strong>of</strong> intestinal fatty acid binding protein (IFABP, aparameter for enterocyte damage), recovery <strong>of</strong> polyethylene glycols (PEGs, a parameter forintestinal permeability), and excretion <strong>of</strong> nitric oxide (NOx, a parameter for bacterialtranslocation) were assessed in urine <strong>of</strong> 141 patients collected 24 to 48 h after start <strong>of</strong>probiotic or placebo treatment and 7 days thereafter. IFABP concentrations in the first 72hours were significantly higher in patients who developed bacteremia, infected necrosis, andorgan failure. PEG recovery was significantly higher in patients who developed bacteremia(PEG 4000), organ failure (PEG 4000), or died (PEG 4000). Probiotic prophylaxis wassignificantly associated with an increase in IFABP (median 362 vs 199 pg/mL), mostevidently in patients with organ failure, and did not influence intestinal permeability. Overall,probiotics decreased NOx but, in patients with organ failure, increased NOx. It wasconcluded that bacteremia, infected necrosis, organ failure, and mortality were all associatedwith intestinal barrier dysfunction early in the course <strong>of</strong> acute pancreatitis. Overall,prophylaxis with this specific combination <strong>of</strong> probiotic strains reduced bacterial translocation,but was associated with increased bacterial translocation and enterocyte damage in patientswith organ failure [228].It has been proposed that probiotics can favorably influence the course <strong>of</strong> critically ill patientswith acute pancreatitis. To address this question, a limited systematic <strong>review</strong> was undertaken(MEDLINE search for articles published in English) to identify randomized, controlled trialsthat compared a group <strong>of</strong> critically ill patients taking probiotics with a group that did not. Tensuch trials, mostly with high risks <strong>of</strong> methodologic bias, were identified. When the data werecombined, the probiotics did not appear to influence mortality or duration <strong>of</strong> hospitalization.