The Use of Prophylaxis Antibiotics to Prevent Acute Pancreatitis Complications: Meta-Analysis of Clinical Trials

Background: Acute pancreatitis (AP) is an inflammation of the pancreas, a serious emergency with no definitive treatment. It may progress to infected necrosis, non-pancreatitis infection, also death that may occur within the first 1 to 2 weeks. The use of prophylactic antibiotics in AP to prevent complications remains a controversy. The objective of this meta-analysis is to assess the benefit of prophylaxis antibiotics administration to prevent the complication.Method: Trials were identified by searching the medical database. Literature range is within the year 1975 to 2021. Review Manager 5.4.1 was used to analyse data extraction and risk of bias of included studies were elaborated. Risk ratio (RR) was calculated with 95% confidence interval (CI). P 0.05 was considered significant.Results: Twenty trials with a total of 1.287 patients of AP were analysed; 646 patients treated with antibiotic prophylaxis and 641 patients treated with placebo. Prophylaxis antibiotics were found to have significant difference between the two groups. The administration of prophylaxis antibiotics lower the risk of non-pancreatic infections (RR = 0.77; 95% CI: 0.62–0.95; p 0.05) and infected pancreatic necrosis (RR = 0.74; 95% CI: 0.58-0.94; p 0.05). Meanwhile, prophylaxis antibiotics were found to be insignificant to lower the risk of mortality (RR = 0.75; 95% CI: 0.54-1.03; p 0.05). Conclusion: Prophylaxis antibiotics lower the risk of non-pancreatic infections and infected pancreatic necrosis, but did not lower the risk of mortality.

P-EUS03 Risk prediction in patients undergoing Endoscopic Necrosectomy for infected pancreatic necrosis

Background Laparotomy for the treatment of patients with infected pancreatic necrosis is associated with high rates of morbidity (∼95%) and mortality (∼50%); this has driven the development of minimally invasive alternatives for the treatment of such cases. Endoscopic Transgastric Necrosectomy (ETN) is an accepted method for debriding infected necrosis in these challenging cases. The National Emergency Laparotomy Audit (NELA) and P-POSSUM scoring systems are well-validated risk stratification tools used nationally for patients undergoing emergency laparotomy. This work aims to determine whether patients undergoing ETN for infected pancreatic necrosis can be risk stratified accurately using both the NELA and P-POSSUM scoring systems. Methods A prospective database of all patients in a single UK centre undergoing ETN from 2011 to 2021 for infected pancreatic necrosis has been maintained. All patients initially underwent an EUS guided stent placement to create a cystgastrostomy before subsequent transgastric necrosectomy. Patient demographics, timing of procedures and short-term post procedural outcomes were recorded. The NELA and P-POSSUM score was calculated at the time of the endoscopic cystgastrostomy. Demographic data were descriptively summarized and ROC analysis was performed to assess the diagnostic accuracy of both the P-POSSUM and NELA score. Data are presented as median (range) Results Sixty-nine patients underwent ETN between 2011 and 2021 with a median age of 54 years-(15-86). Twenty-nine patients-(42%) required ITU admission during their admission. The actual mortality was 10.1%-(7), which was slightly higher than the median of the NELA predicted mortality-(6.7%) but half the median of the P-POSSUM predicted mortality-(21.1%). Median overall predicted mortality for ETN using P-POSSUM was 21.1%-(2.6-85.7%) and with NELA was 6.7%-(0.4-34.3%). The median P-POSSUM score of the patients who died was 33.2%-(6.9-52.4%) compared to the median NELA score which was 17.2%-(0.8-34.3%). The area under the receiver operating characteristics curve-(AUROC) was similar for both the NELA-(0.82, SE = 0.13) and P-POSSUM-(0.75,-SE=0.1). Conclusions Endoscopic Transgastric Necrosectomy is a safe alternative to emergency laparotomy for the debridement of infected pancreatic necrosis. Both the NELA and P-POSSUM scoring systems can effectively stratify those patients at highest risk, however where P-POSSUM scoring may overestimate mortality NELA scoring may underestimate the severity of illness and mortality associated with the disease.

Immune enhancement to prevent infected pancreatic necrosis: A double-blind randomized controlled trial

BACKGROUND&AIMS Infected pancreatic necrosis (IPN) is a highly morbid complication of acute pancreatitis(AP). Since there is evidence of immunosuppression in the early phase of AP, immune enhancement using Thymosin alpha 1 (Tα1), which stimulates both innate and adaptive immunity, may be a therapeutic strategy to prevent IPN. Our aim was to assess the efficacy of early Tα1 treatment on the development of IPN. METHODS We conducted a multicenter, randomized, double-blind, placebo-controlled trial in patients with predicted severe acute necrotizing pancreatitis (ANP). ANP patients with an APACHE II score≥8 admitted within seven days of the advent of symptoms were considered eligible. Enrolled patients were assigned to receive a subcutaneous injection of Tα1 1.6 mg, every 12 hours for the first 7 days and 1.6 mg once a day for the subsequent 7 days or matching placebo (normal saline). The primary outcome was the development of IPN during the index admission. RESULTS From Mar 2017 through Dec 2020, 508 patients were randomized at 16 hospitals, of whom 254 were assigned to receive Tα1 and 254 placebo. During the index admission, 40/254 (15.7%) patients in the Tα1 group developed IPN compared with 46/254 patients (18.1%) in the placebo group (difference -2.4% [95%CI -7.4% to 5.0%]; p=0.47). The results were similar in four predefined subgroups. There was no difference in other major complications, including new-onset organ failure (10.6% vs. 15.0%; p=0.15), bleeding (6.3% vs. 3.5%; p=0.15), and gastrointestinal fistula (2.0% vs. 2.4%; p=0.75) during the index admission. CONCLUSIONS The immune-enhancing Tα1 treatment of patients with predicted severe ANP did not reduce the incidence of IPN during the index admission.