review of literature on clinical pancreatology - The Pancreapedia

However, the recipients <strong>of</strong> the probiotics had fewer infectious episodes (absolute riskdifferente -21 %). This effect was seen particularly in trials employing one combination <strong>of</strong>probiotic agents (Pediococcus pentosaceus, Leuconostoc mesenteroides, Lactobacillusparacasei, Lactobacillus plantarum). Unfortunately, this effect may be overly optimistic, asmethodologic shortcomings could have introduced biases into the trials. Three trials <strong>of</strong>patients with severe acute pancreatitis were not included in this primary analysis because notall <strong>of</strong> the patients were in the intensive care unit. The largest <strong>of</strong> these, and the one with thelowest risk <strong>of</strong> bias, demonstrated that probiotics increased mortality, in part because <strong>of</strong> theprecipitation <strong>of</strong> ischemic bowel disease (in patients who were also receiving postpyloricenteral nutrition infusions). Probiotics also appeared to reduce the incidence <strong>of</strong> antibioticassociateddiarrhea in hospitalized patients, although these trials did not specifically focusonly on those who were critically ill. In summary, it is not clear that probiotics are beneficial(and they may even be harmful) in the critically ill patient group [229].AntibioticsThe aim <strong>of</strong> one study was to analyze the evidence-based use <strong>of</strong> antibiotic therapy in thetreatment <strong>of</strong> acute pancreatitis and to identify factors influencing the introduction <strong>of</strong> antibiotictherapy in the setting <strong>of</strong> transitional country clinical hospital. A retrospective study wasconducted from hospital records <strong>of</strong> patients treated for acute pancreatitis during 2005. Datacollected from patients' histories were compared with indications for antibiotic treatment andantibiotics with demonstrated therapeutic efficacy in acute pancreatitis which were obtainedfrom published <strong>literature</strong>. Antibiotic therapy was used in 68 percent <strong>of</strong> patients with acutepancreatitis. Combination <strong>of</strong> amoxicillin plus clavulanic acid was most frequentlyadministered, either as monotherapy or in combination with metronidazole and/or gentamicin(37 %), followed by cefuroxime (33 %) and cefoperazone (27 %). The choice <strong>of</strong> antibioticwas appropriate in 36 perent <strong>of</strong> study patients; however in 30 percent <strong>of</strong> patients who wereadministered antibiotics had no indication for this therapy; and 47 percent <strong>of</strong> patients whohad indications for receiving antibiotic therapy didn't receive it. In the groups <strong>of</strong> patientstreated with antibiotics, the cost <strong>of</strong> treatment was significantly higher compared to groups <strong>of</strong>patients who were not treated with antibiotics. In addition to antibiotic therapy, the cost <strong>of</strong>treatment was significantly influenced by the length <strong>of</strong> hospital stay and treatment atintensive care unit. The use <strong>of</strong> antibiotics in the setting <strong>of</strong> transitional country universityhospital in patients with acute pancreatitis is not evidence-based. Decision on theintroduction <strong>of</strong> antibiotic therapy is not based on objective parameters <strong>of</strong> disease severity orevidence <strong>of</strong> therapeutic efficacy <strong>of</strong> particular antibiotics. The cost <strong>of</strong> treatment is significantlyincreased by the use <strong>of</strong> antibiotic therapy [230].NecrosectomyTraditional open surgical necrosectomy for treatment <strong>of</strong> infected pancreatic necrosis isassociated with high morbidity and mortality, leading to a shift toward minimally invasiveendoscopic, radiologic, and laparoscopic approaches. Percutaneous drainage is useful as atemporizing method to control sepsis and as an adjunctive treatment to surgical intervention.It is limited because <strong>of</strong> the requirement for frequent catheter care and the need for repeatedprocedures. Endoscopic transgastric or transduodenal therapies with endoscopicdebridement/necrosectomy have recently been described and are highly successful incarefully selected patients. It avoids the need for open necrosectomy and can be used inpoor operative candidates. Laparoscopic necrosectomy is also promising for treatment <strong>of</strong>pancreatic necrosis. However, the need for inducing a pneumoperitoneum and the potentialrisk <strong>of</strong> infection limit its usefulness in patients with critical illness. Retroperitoneal access witha nephroscope is used to directly approach the necrosis with complete removal <strong>of</strong> asequestrum. Retroperitoneal drainage using the delay-until-liquefaction strategy also appears