Masayasu Horibe

Continuous Regional Arterial Infusion of Protease Inhibitors Has No Efficacy in the Treatment of Severe Acute Pancreatitis: A Retrospective Multicenter Cohort Study.

Objective The aim of this study is to assess the effectiveness of continuous regional arterial infusion (CRAI) of protease inhibitors in patients with severe acute pancreatitis (SAP) including acute necrotizing pancreatitis. Methods This retrospective study was conducted among 44 institutions in Japan from 2009 to 2013. Patients 18 years or older diagnosed with SAP according to the criteria of the Japanese Ministry of Health, Labour and Welfare study group (2008) were consecutively enrolled. We evaluated the association between CRAI of protease inhibitors and mortality, incidence of infection, and the need for surgical intervention using multivariable logistic regression analysis. Results Of 1159 patients admitted, 1097 patients with all required data were included for analysis. Three hundred and seventy-four (34.1%) patients underwent CRAI of protease inhibitors and 723 (65.9%) did not. In multivariable analysis, CRAI of protease inhibitors was not associated with a reduction in mortality, infection rate, or need for surgical intervention (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.47–1.32, P = 0.36; OR 0.97, 95% CI 0.61–1.54, P = 0.89; OR 0.76, 95% CI 0.50–1.15, P = 0.19; respectively). Conclusions Continuous regional arterial infusion of protease inhibitors was not efficacious in the treatment of patients with SAP.

Continuous Regional Arterial Infusion of Protease Inhibitors for Treatment of Severe Acute Pancreatitis: Systematic Review and Meta-Analysis.

Objective We performed a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs) to assess the benefit and risk of continuous regional arterial infusion (CRAI) of protease inhibitors (CRAIpis) in patients with severe acute pancreatitis (SAP) or acute necrotizing pancreatitis (ANP). Methods The search was performed using the key words “pancreatitis” and “regional arterial infusion.” All language studies involving adult cases of SAP or ANP, which assessed the impact of the CRAIpis, were included. Results Our analysis included 8 observational studies and 2 RCTs from 376 potentially relevant articles. With regard to the observational studies, the CRAIpi was significantly associated with decreased both mortality (odds ratio, 0.40; 95% confidential interval [CI], 0.25–0.64; P = 0.0001) and the need for urgent surgical intervention (odds ratio, 0.22; 95% CI, 0.12–0.3; P < 0.0001). In the RCTs, the application of CRAIpi tends to decrease the mortality but does not reach the significance (risk reduction, −0.12; 95% CI, −0.36–0.12; P = 0.33). Conclusions The CRAIpi has the potential to reduce the mortality or the need for urgent surgical intervention in cases of SAP or ANP. Further, large multicenter trials are needed to refute or confirm our findings.

Plasmapheresis therapy has no triglyceride-lowering effect in patients with hypertriglyceridemic pancreatitis.

Kyohei Miyamoto, Masayasu Horibe, Masamitsu Sanui, Mitsuhito Sasaki, Daisuke Sugiyama, Seiya Kato, Takahiro Yamashita, Takashi Goto, Eisuke Iwasaki, Kunihiro Shirai, Kyoji Oe, Hirotaka Sawano, Takuya Oda, Hideto Yasuda, Yuki Ogura, Kaoru Hirose, Katsuya Kitamura, Nobutaka Chiba, Tetsu Ozaki, Taku Oshima, Tomonori Yamamoto, Keiji Nagata, Tetsuya Mine, Koji Saito, Motohiro Sekino, Tomoki Furuya, Naoyuki Matsuda, Mineji Hayakawa, Takanori Kanai and Toshihiko Mayumi

Validation of the efficacy of the prognostic factor score in the Japanese severity criteria for severe acute pancreatitis: A large multicenter study

Background The Japanese severity criteria for acute pancreatitis (AP), which consist of a prognostic factor score and contrast-enhanced computed tomography grade, have been widely used in Japan. Objective This large multicenter retrospective study was conducted to validate the predictive value of the prognostic factor score for mortality and complications in severe AP patients in comparison to the Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Methods Data of 1159 patients diagnosed with severe AP according to the Japanese severity criteria for AP were retrospectively collected in 44 institutions. Results The area under the curve (AUC) for the receiver-operating characteristic curve of the prognostic factor score for predicting mortality was 0.78 (95% confidence interval (CI), 0.74–0.82), whereas the AUC for the APACHE II score was 0.80 (95% CI, 0.76–0.83), respectively. There were no significant differences in the AUC for predicting mortality between two scoring systems. The AUCs of the prognostic factor scores for predicting the need for mechanical ventilation, the development of pancreatic infection, and severe AP according to the revised Atlanta classification were 0.84 (95% CI, 0.81–0.86), 0.73 (95% CI, 0.69–0.77), and 0.83 (95% CI, 0.81–0.86), respectively, which were significantly greater than the AUCs for the APACHE II score; 0.81 (95% CI, 0.78–0.83) for the need for mechanical ventilation (p = 0.03), 0.68 (95% CI, 0.63–0.72) for the development of pancreatic infection (p = 0.02), and 0.80 (95% CI, 0.77–0.82) for severe AP according to the revised Atlanta classification (p = 0.01). Conclusion The prognostic factor score has an equivalent ability for predicting mortality compared with the APACHE II score. Regarding the ability for predicting the development of severe complications during the clinical course of AP, the prognostic factor score may be superior to the APACHE II score.

Timing of oral refeeding in acute pancreatitis: A systematic review and meta-analysis

Background and aim The optimal timing of oral refeeding in acute pancreatitis is unclear. This study aimed to perform a systematic review with meta-analysis of randomized controlled trials (RCTs) that compared early oral refeeding with standard oral refeeding in acute pancreatitis. Methods PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched in order to identify RCTs eligible for inclusion in the systematic review. The weighted mean differences (WMDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Results Five eligible RCTs were included. Compared with standard oral refeeding, early oral refeeding significantly decreased the length of hospital stay (WMD: −2.22, 95%CI: −3.37 to −1.08, p = 0.0001). Although there was heterogeneity (I2 = 56%, p = 0.06), subgroup analysis of the refeeding criteria (immediate group and hungry group) eliminated the heterogeneity. There was no significant difference between the early refeeding group and standard refeeding groups with respect abdominal pain and distension (OR 1.14; 95%CI 0.65–1.99 and OR 1.53; 95%CI 0.81–2.90). Conclusions Compared with standard oral refeeding, early oral refeeding safely reduced the length of hospital stay in patients with acute pancreatitis.

Absence of high-risk stigmata predicts good prognosis even in severely anemic patients with suspected acute upper gastrointestinal bleeding

Background The need for a blood transfusion, defined as hemoglobin < 70 g/L, is the measure for assessing the risk levels in patients with upper gastrointestinal bleeding (UGIB). However, not all patients with a low hemoglobin level have a poor prognosis. Objective We assessed the clinical predictive factors associated with poor short-term prognosis in patients with a low hemoglobin level. Methods In this prospective cohort study, all consecutive patients with suspected acute UGIB at Tokyo Metropolitan Tama Medical Center were enrolled between 2008 and 2015. Then, we extracted those who needed a blood transfusion (hemoglobin < 70 g/L) and explored the variables associated with all-cause mortality within 28 days after presentation. Results Among 1307 patients, 311 needed a blood transfusion and 13 (4.2%) died from all causes. The presence of high-risk stigmata requiring endoscopic treatment (peptic ulcers; Forrest scores Ia, Ib and IIa; varices with current bleeding or signs of recent bleeding; and spurting or gushing bleeding or visible vessel in other diseases), diagnosed by emergency endoscopy, was a unique factor affecting mortality (odds ratio: 8.47, 95% confidence interval: 1.45–160, P = 0.01). Patients without high-risk stigmata neither died from UGIB nor had rebleeding, irrespective of the hemoglobin levels. Conclusions Patients without high-risk stigmata showed a good prognosis even if they needed a blood transfusion. This result could facilitate triage of patients with suspected acute UGIB who only need a blood transfusion.

The Prognosis of Severe Acute Pancreatitis Varies According to the Segment Presenting with Low Enhanced Pancreatic Parenchyma on Early Contrast-Enhanced Computed Tomography: A Multicenter Cohort Study

Objective The aim of this study was to investigate the outcomes of severe acute pancreatitis (SAP) according to the segment presenting with low enhanced pancreatic parenchyma (LEPP) on early contrast-enhanced computed tomography. Methods This was a post hoc analysis of a multicenter, retrospective study conducted at 44 institutions in Japan. Patients diagnosed as having SAP according to the Japanese Severity Score between January 2009 and December 2013 were included. We compared the effect of LEPP in each segment on mortality. Results A total of 1097 patients were assessed. The numbers of patients with LEPP in the pancreatic head (Ph), body (Pb), or tail (Pt) were 272, 273, and 204 (with some overlaps), respectively. In multivariate analysis, LEPP in Ph and Pt was significantly related to mortality (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.11–3.40 [P < 0.05], for LEPP in Ph; OR, 2.44; 95% CI, 1.27–4.67 [P < 0.05], for LEPP in Pt), but LEPP in Pb was unrelated to mortality (OR, 0.70; 95% CI, 0.35–1.37; P = 0.30). Conclusions Presence of LEPP in Ph and Pt on early contrast-enhanced computed tomography was independently associated with increased mortality in SAP. These patients require close observation to ensure timely and adequate intervention.

Curative resectability of gastrointestinal cancer identified from iron deficiency anemia

The present study aimed to clarify the staging and curative resectability of gastrointestinal cancer found through iron deficiency anemia (IDA). An electronic database was used and females >51 and males >18 years old were identified who had been diagnosed with IDA at the internal medicine outpatient clinic of Asahi General Hospital (Chiba, Japan) from 1 April 2010 to 31 March 2012. IDA was defined as a hemoglobin level of <135 g/l for males and <120 g/l for females, combined with a serum ferritin level of <33.71 pmol/l. Of the 472 patients who had been diagnosed with IDA, 347 patients underwent either a gastroscopy and/or colonoscopy, including 120 patients who had undergone both gastroscopy and colonoscopy, 197 patients who only underwent gastroscopy, and 30 patients who only underwent colonoscopy. In total, 125/472 patients diagnosed with IDA did not undergo a gastroscopy or a colonoscopy. From the 50 patients who were diagnosed with cancer as a result of the investigation, 24 patients had gastric cancer and 23 patients had colorectal cancer. Of the gastric cancer patients, 6 patients were stage I, 3 patients stage II, 5 patients were stage III and 9 patients were stage IV. In colorectal cancer, 9 patients were stage II, 8 patients were stage III and 4 patients were stage IV. Curative surgery including endoscopic treatment was performed on 14 gastric cancer patients and 17 colorectal cancer patients of stage III or lower. Malignancies were found in 50 patients with IDA, and curative surgery was performed on >50% of the patients.